Permission to attend Student Convention

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Permission to attend Student Convention

To whom it may concern:

Permission is hereby granted for my son ___ daughter ___ Name __________________________________

To attend the Southern Plains Junior Student Convention in Cedar Hill, Texas under the supervision of:

Name of Sponsor and School

Name of Parent/Guardian __________________________________________________________________

Phone Numbers: Home _________________ Work __________________ Emergency__________________

Address _______________________________ City _____________________ St ___ Zip Code __________

Sponsor, Staff, and Contestant

Permission For Medical Treatment and Release of Liability

Date __________________________

I hereby give permission for Southern Plains Junior Convention medical staff, director, or dean to obtain medical treatment for:

___________________________________________________________ Age _______________________

I/he/she may be given Tylenol, cough syrup, or Pepto-Bismol if needed. Yes ___ No ___

If allergic to any medications, please specify. ________________________________________________

If presently on medication, please specify. __________________________________________________

___ Check here if there are physical or any special instructions, and fill out the

Special Medical Treatment Form.

I understand that I am responsible for accident and medical insurance and any expense for attention if needed en route to and from convention and throughout the duration of the convention. I hereby release Southern Plains Junior Convention and the Host Campus from any liability for death or injury that may result from my voluntary participation in any activity while at and en route to and from convention.

______________________________________________________

Signed

_______________________________________________________

If Student, Relationship: Father/Mother/Guardian

_______________________________________________________

Address/City/State/Zip Code

_______________________________________________________

Family Physician and Phone Number

_______________________________________________________

Name of School, Customer Number, and Phone Number

_______________________________________________________

Name of Sponsor and Home Phone Number