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PERMISSION SLIP
Legal Guardian signature below gives consent to treatment
In the event of illness or injury, I do hereby consent to whatever x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care that are considered necessary in the best judgment of the attending physician, surgeon, or dentist and performed by or under the supervision of a member of the medical staff of the hospital or facility furnishing medical or dental services, and the undersigned agrees to pay for such medical care whether or not the costs are insured by parents’/guardians’ health insurance.
Legal Guardian signature below gives waiver of claims
Parent/guardian for him/herself and for his/her child/ward by signature herein below waives any and all claims against Annie Lee, Queens library branches, its workers, and its scout and parent volunteers for injury, accident, illness, or death during or by reason of the trip or excursion.
Legal Guardian below gives agreement for consequences on following rules
Undersigned agrees that participants are to abide by all rules and regulations governing conduct during the trip and that any violation of these rules and regulation can result in parent/guardian being called to come and pick up child. No refund of fees will be made.
I, _________________________ (print parent/guardian name), give my daughter ______________________ permission to attend Annie Lee’s Gold Award Workshops hosted during the following times and places (check all applicable):
□ August 2nd (Tues) 1:30-3:30PM @ Fresh Meadows library
□ August 3rd (Wed) 2-3:30PM @ Pomonok library
□ August 4th (Thurs) 3-5PM @ Windsor Park
□ August 8th (Mon) 4-5:30 @ East Flushing library
□ August 10th (Wed) 2-3:30 @ Pomonok library
In case of emergency, I can be reached at:
Day Phone:
Evening Phone:
Cell phone:
Address:
Doctor or other Contact, Name & Tel:
This form must be signed by both parents/legal guardians (in English)
| (sign, print) | (sign, print) |
