NASHUA CATHOLIC
    REGIONAL JUNIOR HIGH SCHOOL

          6 BARTLETT AVENUE  NASHUA, NEW HAMPSHIRE  03064      (603)882-7011   Fax (603)594-8955

Please click on this link to download and print the permission slip, then fill out the information and return the form to school.

(Note that the downloadable form requires Adobe® Reader®, a free, universal software that lets you open, view, search, and print Adobe Portable Document Format (PDF) files with built-in security features. If you do not have Adobe Reader, please click on the icon below to get it from www.Adobe.com.)

DIOCESE OF MANCHESTER

PERMISSION SLIP

ACTIVITY:                     

 DATE OF ACTIVITY:          

TIME OF DEPARTURE:          TIME OF RETURN:  

NAME OF MINOR CHILD/WARD and Grade

 ______________________________________________

Please allow my minor child/ward to participate in the activity listed above.  My child/ward is physically fit and capable of taking part in this activity.

 I agree to have my child/ward transported via ambulance and/or treated for emergency medical or dental problems if an emergency arises.  I accept full responsibility for all medical expenses incurred as a result of my child/ward’s participation in this program.

 On the lines below I have listed any medical conditions, physical disability, allergy to medicine, etc. which is relevant to rendering medical care to my child/ward if he/she needs emergency medical care:

During the time of this activity, I can be reached at __________________________________

                                                                                                (Telephone Numbers)

 Signed this __________________ day of ___________________, 20 _________.

________________________________       ______________________________

            Parent/Guardian Name (print)                                                           Parent/Guardian Signature

Copyright © 2004 Nashua Catholic Regional Junior High School