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  • 18 Plus

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    Tara Osendorf
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    Box City 18+ Permission Slip Name_______________________________________________ Birth Date___-_____________________ Address___---_____________________................_____________________ Preferred Phone Number __________________________ _____________________ Family Physician___ ______________ Phone Number ____________________ medical Insurance Company ___________________ Policy #______________ I understand that the Box City leaders will determine what is appropriate behavior. I agree I will not have in my possession or use anything which is or could be considered a weapon;

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    Box City 18+ Permission Slip Name_______________________________________________ Birth Date___-_____________________ Address___---_____________________................_____________________ Preferred Phone Number __________________________ _____________________ Family Physician___ ______________ Phone Number ____________________ medical Insurance Company ___________________ Policy #______________ I understand that the Box City leaders will determine what is appropriate behavior. I agree I will not have in my possession or use anything which is or could be considered a weapon;

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Scarica in formato PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    104 visualizzazioni1 pagina

    18 Plus

    Caricato da

    Tara Osendorf
    Box City 18+ Permission Slip Name_______________________________________________ Birth Date___-_____________________ Address___---_____________________................_____________________ Preferred Phone Number __________________________ _____________________ Family Physician___ ______________ Phone Number ____________________ medical Insurance Company ___________________ Policy #______________ I understand that the Box City leaders will determine what is appropriate behavior. I agree I will not have in my possession or use anything which is or could be considered a weapon;

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Scarica in formato PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
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    Box City 18+ Permission Slip

    Name_____________________________________________________________________ Birth Date_________________________

    Address_____________________________________________________________________________________________________

    Preferred Phone Number _______________________________________________________________________________________

    Participant Allergy/Medical Concerns_____________________________________________________________________________

    ____________________________________________________________________________________________________________

    Name & Phone Number of Emergency Contact:

    Name______________________________________ Phone Number______________________

    Family Physician_____________________________ Phone Number______________________

    Medical Insurance Company__________________________ Policy #_____________________

    I understand that the Box City leaders will determine what is appropriate behavior, and I agree I will behave appropriately and act
    respectfully toward those with whom I participate. I agree I will not have in my possession or use anything which is or could be
    considered a weapon; any type of explosive material; chemicals of any kind including, but not limited to, tobacco, alcohol, or any
    other drug, unless they are listed on my medical form as prescribed medication.

    Participant Signature______________________________________________________________Date_________________________

    Box City 18+ Permission Slip

    Name_____________________________________________________________________ Birth Date_________________________

    Address_____________________________________________________________________________________________________

    Preferred Phone Number _______________________________________________________________________________________

    Participant Allergy/Medical Concerns_____________________________________________________________________________

    ____________________________________________________________________________________________________________

    Name & Phone Number of Emergency Contact:

    Name______________________________________ Phone Number______________________

    Family Physician_____________________________ Phone Number______________________

    Medical Insurance Company__________________________ Policy #_____________________

    I understand that the Box City leaders will determine what is appropriate behavior, and I agree I will behave appropriately and act
    respectfully toward those with whom I participate. I agree I will not have in my possession or use anything which is or could be
    considered a weapon; any type of explosive material; chemicals of any kind including, but not limited to, tobacco, alcohol, or any
    other drug, unless they are listed on my medical form as prescribed medication.

    Participant Signature______________________________________________________________Date_________________________

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