has my permission to attend the E-4 Service Unit �Cookie Rally� at Shaull Elementary School on January 4, 2009 from 2:00 � 4:00PM. Please bring your child to Shaull Elementary School at 1:45 and plan to spend an afternoon of fun learning about Girl Scout cookies with her.
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