| Permission Form for REACH Out Journalism Club 2008-2009 School Year |
| I hereby give permission for my child/student, __________________________________ to participate in the REACH Out Journalism Club. I understand that my student will be under the supervision of Sabrina Camacho and/or Tara Williams. I have discussed with my student proper rules of conduct and behavior for this activity. I agree not to hold REACH or any chaperone responsible for any injuries, damages, or loss that might occur during this activity. I give permission to the chaperones to provide or arrange for medical care and treatment for my child should he or she need it during this activity. I understand that I am to have my student to the Irmo Library meeting room by 1:00 p.m. on the first Wednesday of each month. I understand that the Journalism Club meetings are year-round. I also understand that I am to have my child picked up by 2:30 p.m. on meeting days and that the chaperones are not responsible for my child should I not be there. If I have not made previous arrangements (in writing, please), the chaperones will tell my child to go into the library and wait for my arrival. |
| ___________________________________________________________________________ Print Parent's or Guardian's Name Parent or Guardian Signature ___________________________________________________________________________ Home Address/City/Zip Home Phone cell/emergency # ___________________________________________________________________________ Name of Medical Insurance Provider Policy Number ___________________________________________________________________________ Name of Policy Holder Name of primary care physician ___________________________________________________________________________ Address/Phone where parent can be Alternate emergency contact name/telephone reached during this event Please list any alergies (especially to medications): ___________________________________ ___________________________________________________________________________ Medication conditions chaperones should be aware of, including any behavior problems, prescriptions or medications child takes: __________________________________________ ___________________________________________________________________________ |