IN LOCO PARENTIS FORM
STATE OF ILLINOIS COUNTY OF DUPAGE I, natural guardian of _____________________________________, a minor, do hereby designate GECC appointed chaperones to act as parent in loco parentis of my child during the period of the Glen Ellyn Children's Chorus' participation in the tour to Grand Rapids, Michigan, March 17- 19, 2006 , as parent and
I give full authority to said persons to perform such acts as are deemed appropriate in the best interest of the child. The Glen Ellyn Children's Chorus has received a medical form on my child, and this form will accompany the chaperones. As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of my child, a minor, in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after reasonable effort has been made to reach me.
Parent or Legal Guardian
Date
TWO SIDED FORM