YOUTH UNITED FOR CHANGE, INC.

1910 Front Street Philadelphia, PA 19122 (Office) 215-423-9588 TRIP PERMISSION SLIP Trip Destination: Harrisburg, Pennsylvania Trip Date: Wednesday, June 13th Type of Trip: Demonstration at Governors Mansion Special Conditions: We will leave the YUC office at 1910 N. Front Street at 7:00 AM on Wednesday, June 13th, 2012 and we will be returning to Philadelphia on the same day by approximately 5 PM. Your son/daughter will be given SEPTA tokens to return home. By signing this permission slip you are giving your son/daughter permission to attend the trip. Your son/daughter will be missing school and is responsible for making up any school work. Any questions contact: Fred Ginyard, Organizer, 215-892-7087; Anand Jahi, Organizer, 215-238-6970; Claire Galpern, Organizer, 267-340-6009; Donnell Reguster, Organizer, 267414-3568; Priya Johnson, Organizer, 678-372-1558; Saeeda Washington, Organizer, 267-8162209

I, the undersigned parent or guardian of _________________________ give my permission for

Name of Student

him/her to go on this trip. I also consent and allow the trip leaders or bearer of this document to administer first aid and/or secure medical attention for the above named minor as such leader or bearer deems proper. I understand that an effort will be made to contact me if medical treatment should be needed. Youth United for Change will not dispense ANY medication to the above named minor at any time. This authorization and consent may be presented to emergency medical staff if such emergency medical care is required. In exchange for the above named minors opportunity to participate in the trip, I release and hold harmless Youth United for Change form and against any and all claims for injuries or loss from participation in the trip, including or failure to render medical treatment, and any claim based on any form of negligence. _____________________________ ________________________________ Signature of Parent/Guardian Home phone number Address: _____________________________________________________________________ Family doctor and clinic: _________________________________________________________ Youth Birthdate: ______________________ Tetanus Toxoid Booster: ____________________ Allergies to drugs or food?________________________________________________________ Any special medications, chronic health problems or any other important information we should know about your child?
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Health Insurance: _______________________ Policy Number: __________________________