2009 Substance-Free Graduation Party Consent Form
__________________________________ Student Name (please print or type) __________________________ Parent/Guardian Name (please print or type)
I have read the letter regarding the rules and guidelines for the Graduation Party, and I agree to abide by them. ______________________ Student Signature ___________________________________ Date
I have read the information in the parent letter about the Graduation Party and agree with the contents. I hereby waive and release the Graduation Party Committee from any and all liability for damage, injury, and illness while my son/daughter is a participant. ________________ Parent/Guardian Signature ___________________________________ Date _____________________
________________________________________________________ Parent/Guardian Address City Zip
Home Telephone (include Area Code)________________________________________________________ Parent / Guardian Cell (include Area Code_____________________________________________________ Person to Call in Emergency ________________________________________________________________ Telephone (include Area Code) _____________________________________________________________ Hospital of choice _________________________________________________________________________ Insurance Carrier _________________________________________________________________________ Insurance Group and/or Member No. __________________________________________________________
RETURN COMPLETED FORM TO MAIN OFFICE BY MAY 8, 2009
11999 SE Fuller Road | Milwaukie, OR 97222 | 503.659.155 | 503.659.2535 Fax