Health Questionnaire

Please state any physical handicap, allergies, medication or restrictions:

________________________________________________________________________

Is the student allergic to any medicines?

In case of emergency, parent or guardian can be reached at:

Name:_____________________ Phone: (______)_________________

Parental Permission

As the parent or guardian of the student mentioned above, I hereby grant permission of attendance as well as authorize the staff to make any necessary decisions in case of emergency and will be responsible for any expenses.

Parent/Guardian Name: ____________________________________

Signature: _________________________________ Date: _____________

****We need chaperones/drivers for this event. It would be great if dads joined us! Please volunteer J

¨ YES, I can chaperone/drive for this event.

Chaperone Name: ____________________________

Primary Phone Number: _______________________