Blessed Sacrament Church at 3127 James St, Syracuse, NY 13206 US - Permission Slip and Medical Information

I, _______________________________________ , parent(s)-guardian of

_________________________, give permission for my son/daughter to

attend ______________________________ on ___________________

from_________.  As a parent, legal guardian, I remain fully responsible for any

personal action or damage incurred by my child. I also give permission for

emergency medical treatment administered, if I am unable to be contacted, and

all expenses will be my responsibility.

HOME PHONE # ____________________________

EMERGENCY PHONE # _____________________

Medical Information: Name of Insurance _______________________________

I understand that once my child is at _________________, that he/she is not to

leave the premises.  If your son/daughter must leave before the end of the event,

please note the hour below and who will pick him/her up.

HOUR LEAVING ______________________

TRANSPORTED PROVIDED BY ___________________________________

    (Parent/Guardian Signature)                                                  (Date)