"RUFFING ROADSTERS"
PERMISSION SLIP AND MEDICAL INFORMATION FORM
Student Information
Student *
First name
Your answer
Student *
Last name
Your answer
Student’s grade *
Teacher *
My child has the following physical and/or medical conditions or limitations:
Your answer
My child has the following allergies:
Your answer
Name of person(s) who will pick up your child from practice *
Your answer
Parent *
First name
Your answer
Parent *
Last name
Your answer
Parent’s Email *
Your answer
Phone number during practice *
Your answer
Student Attendance Signup
My child will attend on following dates:
Week 1
May - 1st / 2nd / 3rd
Week 2
May - 8th / 9th / 10th
Week 3
May - 15th / 16th / 17th
Week 4
May - 22nd / 23rd / 24th
Parent Volunteer Signup
I am available to help on the following specific dates:
Week 1
May - 1st / 2nd / 3rd
Week 2
May - 8th / 9th / 10th
Week 3
May - 15th / 16th / 17th
Week 4
May - 22nd / 23rd / 24th
Parental Consent
I give permission for my child to take part in the physical activities of the Ruffing Roadsters run/walk program. *
Required
I hereby release Ruffing Montessori School and the above named program of all liability and responsibility in case of accident in any manner connected with the activities associated with the program or arising from any occurrence during its activities from its commencement through its termination. *
Required
Parent Signature *
By typing your name here, you agree that this constitutes a signature
Your answer
Form Submission Date *
MM
/
DD
/
YYYY
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