has my permission to go to the Bethany Village Nursing Home in Mechanicsburg on Saturday May 30 from 2:00 PM to 3:30 PM.
We will meet at Bethany Village at 1:45pm and your daughter can be picked up at 3:45pm.
Please call me at 732-8849 or e-mail me at [email protected] and let me know if your daughter will be going.
She is in good physical condition and has had no serious illness or operation since her last health examination. During the activity I may be reached at:
Address: _______________________________________________
Phone: _____________________________
If I cannot be reached in case of an emergency, the following person is authorized to act in my behalf:
Name and Address: _______________________________________
________________________________________
Relationship to participant: ______________________
Phone number: ____________________
Physician�s name and number: __________________________
___________________________
Parent�s Signature: ____________________________________
Date: ___________________
My daughter _______ will ________ will not be attending
I would be willing to stay and help ______Yes ____ No