2020 PERMISSION SLIP AND EMERGENCY FORM
Event Timing: Friday May 29, 2020 9:30 pm - Saturday May 30, 2020 5:00 am
Event Address: PHS 3661 Ponderosa Rd, Shingle Springs, CA 95682
Contact us at: committee@PHSsobergradnight.org
Email address *
Attendee and Parent / Guardian Agreement
I/We, the undersigned parent/guardian of Student Name listed below, a member of the 2020 Ponderosa Senior Class, authorize the PHS Sober Grad Night committee, representatives for the undersigned in our absence, to consent to x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and/or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the Medical Act, whether such diagnosis or treatment is rendered at the office of said physician or any duly licensed medical facility. It is understood this authorization is given in advance of any specific diagnosis, treatment, or hospital care required, but is given to provide authority and power on the part of the aforementioned PHS Sober Grad Night Committee representatives to give specific consent in any medical emergency or hospitalization which the aforementioned physician, in the exercise of best judgment, may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. The undersigned agrees to adhere to all the rules of the PHS Sober Grad Night event and bear all costs incurred as a result of any medical treatment and/or destruction/action by the student. This authorization will remain in effect for the duration of the event including but not limited to the student’s check-in at Ponderosa High School.

I/We agree to hold the PHS Sober Grad Night Committee and its volunteers harmless from any and all liability, actions, and causes of action, debts, claims, and demands of every kind and nature which may arise by or in connection with participation by my/our student/ward in any activities related to PHS Sober Grad Night activities.

I, member of the 2020 Ponderosa Senior Class, agree to abide by all of the standard PHS rules in the PHS Student Handbook. This is a drug free event and I agree that I will not possess or consume any alcohol, tobacco products, vaping or illegal drugs. Should I be caught with any of the above items I understand that my parents will be called and possible local authorities.

I/We authorize Ponderosa High School Sober Grad Night to utilize any photographed or video graphed images in brochures, flyers, displays, and website or for other promotional purposes.
Student Name (first and Last) *
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Parent/Guardian Name *
Your answer
Parent/Guardian Email *
Your answer
Parent/Guardian Phone # *
Your answer
Student Email *
Your answer
Student Phone # *
Your answer
Allergies? *
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Medications? *
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If yes to either of the above questions please explain.
Your answer
Dietary restrictions *
Please check below how you will pay the $60 for your students ticket. Payment must be received within 5 business days of submission *
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By signing below I, member of 2020 PHS Senior Class agree to all of the terms and conditions mentioned above. *
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By signing below I, parent/guardian agree to all of the terms and conditions mentioned above. *
Your answer
A copy of your responses will be emailed to the address you provided.
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