"RUFFING ROADSTERS"
PERMISSION SLIP AND MEDICAL INFORMATION FORM
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Student Information
Student *
First name
Student *
Last name
Student’s grade *
Teacher *
My child has the following physical and/or medical conditions or limitations:
My child has the following allergies:
Name of person(s) who will pick up your child from practice *
Parent *
First name
Parent *
Last name
Parent’s Email *
Phone number during practice *
Student Attendance Signup
My child will attend on following dates:
Week 1
April 30th / May 1st / May 2nd
Week 2
May -  7th / 8th / 9th
Week 3
May -  14th / 15th / 16th
Week 4
May -  21st / 22nd / 23rd
Parent Volunteer Signup
I am available to help on the following specific dates:
Week 1
April 30th / May 1st / May 2nd
Week 2
May -  7th / 8th / 9th
Week 3
May -  14th / 15th / 16th
Week 4
May -  21st / 22nd / 23rd
Parental Consent
I give permission for my child to take part in the physical activities of the Ruffing   Roadsters run/walk program.   *
Required
I hereby release Ruffing Montessori School and the above named program of all liability and responsibility in case of accident in any manner connected with the activities associated with the program or arising from any occurrence during its activities from its commencement through its termination. *
Required
Parent Signature *
By typing your name here, you agree that this constitutes a signature
Form Submission Date *
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YYYY
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