Permission Slip

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Permission Slip

Email *

Participant Name *

Parent/Guardian Name *

Date of Birth *

YYYY

Permission

I give permission for my youth (named above) to attend the C.H.A.M.P Inc. sponsored trip to ___________ as outlined below.

I further give permission for my youth to be transported to and from the event. I agree to provide transportation to and from the departure site on the stated dates and time;

Medical Information and Medical Authorization

List any severe allergies (bee stings, nuts, food, etc): *

List any medication allergies: *

Does your child have any significant health issues? If so, please explain: *

List any medications, including over the counter, which your child will need during the trip: *

Parent Signature

I, (Parent/Legal Guardian), as the undersigned parent or legal guardian of (participant), do hereby give permission for my child to participate in the trip to;

Furthermore, I do agree that I will not hold C.H.AM.P. Inc., its partners, or volunteers serving on its behalf, liable in case of accident, injury, and loss or damage of property in connection with the trip/activities. This shall include any incidents which may occur during, on the way to, or returning from the above stated event.

In addition, if I cannot be personally contacted, I give the bearer of this document my permission to authorize any emergency medical care that may appear necessary.

I agree to the statements mentioned above *

Yes

Required

Parent/Guardian Phone No. *

Parent/Guardian Alternate Phone No.

Emergency Contact Name *

Emergency Contact Phone No. *

Emergency Contact Relationship *

Youth Acknowledgement

I understand that my participation at C.H.A.M.P. Inc. sponsored activities is a privilege. I will conduct myself appropriately at all times which will allow me to maintain opportunities to attend future activities by demonstrating appropriate and respectful behavior.

In order to participate in this trip and future events, I agree to the following:
• I will treat others with respect…no profanity, inappropriate yelling or “put-downs.”
• I will refrain from being physical with anyone.
• I will stay with the group AT ALL TIMES unless accompanied by an approved chaperone.

I also understand that if, at any time, I fail to meet the behavior expectations for activity attendance, I will not be considered for participation in any future events/activities.

I agree to the statements mentioned above *

Yes

Required

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