|||

Parental Permission Form

- PARISH LIFE

Appalachia Service Project Parental Permission Form
The maximum number of form submissions has been reached. This form is currently not available.
- Student Information
  
  Student Name REQUIRED Please fill out this field. Please enter valid data.
  
  School REQUIRED Please fill out this field. Please enter valid data.
  
  Grade REQUIRED Please fill out this field. Please enter valid data.
- Parent Authorization
  
  By checking the box below, my son/daughter has permission to participate in the Appalachia Service Project. I understand that this program is under adult supervision and that reasonable efforts will be made to minimize risks of injury to participants.
  
  Parent/Guardian #1: Please check here to provide your authorization:
  I Agree Please select this field.
  
  Print Name: REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian #2: Please check here to provide your authorization:
  I Agree Please select this field.
  
  Print Name: Please enter valid data.
  
  Phone # (During this Trip) Please enter valid data.
  
  Cell Phone # (During this Trip) REQUIRED Please fill out this field. Please enter valid data.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Address (During This Trip) REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Emergency Information
  
  List any conditions, e.g. allergies, other medical or mental health problems which should be called to the attention of the Group Leaders: Please enter valid data.
  
  If I cannot be reached in the event of an emergency, the following person is authorized to act on my behalf:
  
  Name: REQUIRED Please fill out this field. Please enter valid data.
  
  Relationship to Participant: REQUIRED Please fill out this field. Please enter valid data.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Address: REQUIRED Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  In case of medical emergency, I understand every effort will be made to contact the parents/guardian of the participant and authorized person above. In the event that I cannot be reached, I hereby give my permission to the physician selected by the program director to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery if deemed necessary for my child as named above.
  
  Parent/Guardian: Please check here to provide your authorization:
  I Agree Please select this field.
  
  Date: REQUIRED Please fill out this field. Please enter valid data.
Submit

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.