WEST TEXAS AREA ALATEEN

PERMISSION TO ENGAGE IN A CONFERENCE TRIP

PARENTS:                  Read, complete and SIGN this form.

ALATEENS:                Return this COMPLETED form to your sponsor accompanying

 you to the _____________________________________

                    (Name of function)

DATE:  _____________________

To the parent/guardian/custodian of __________________________________________

                                                                 (Name of Alateen)

Your daughter/son/ward wishes to participate in the _____________________________

                                                                                    (Name of function)

This is not just a fun weekend.  THE PRIMARY PURPOSE of the function is to share experience, strength and hope with other teenagers in order to gain knowledge and understanding of themselves and others through the Al-Anon/Alateen program.

Attached is a copy of the BEHAVIOR RULES AND PROCEDURES for this function.  You and your teenager must sign it and it must be turned in with this form.  Violations of these guidelines render the violator subject to the consequences, including being sent home.

PLACE OF FUNCTION: __________________________________________________

STARTING TIME: ________________________________________________________

APPROXIMATE RETURN TIME: __________________________________________

MODE OF TRANSPORTATION: ___________________________________________

SPONSOR(S) IN CHARGE: ________________________________________________

I agree that _________________________ is in charge and will at all times make decisions for the best interest of all members of the group.

TOTAL FUNCTION FEE:  ______________________

Name of parent/guardian/custodiAN:  ________________________________________

ADDRESS:                                            _____________________________________________________

PHONE #:                                              _____________________________________________________

NEAREST RELATIVES NAME:        _____________________________________________________

RELATIONSHIP:  _________________________ PHONE #: _______________________________

HOSPITAL/ACCIDENT INS:    ______ YES ______ nO

INSURANCE COMPANY: __________________________________________________________

pOLICY NUMBER: ___________________________________

i _______________________________, hereby grant permission for _____________________________________

(Print parent/guardian/custodian name)                                                          (Print attendee’s name)

to travel to and take part in the ________________________________________ under the supervision of:

_________________________________________

(print name of accompanying Sponsor(s)/Adult(s)

AUTHORIZATION TO OBTAIN MEDICAL CARE

___________________________________________

(Name of function)

I HEREBY AUTHORIZE _____________________________________________ who is the Sponsor of _______________________________________________ to obtain any necessary medical care for me/my child during the _____________________________ weekend.

DATE OF BIRTH: _________________________

Circle any of the following diseases/problems if you have/have had any of them:

Are you allergic to any foods, pollens or drugs?

Have you had a reaction to any of the following:  (please circle)

Do you have any condition, illness or problems not listed above that you think we should know about?  Please explain:

List any prescriptions, pills or remedies that you will be carrying with you.

Dated this ______________ Day of ________________ 20_____

Signature of Parent/Guardian/Custodian if under 18 ___________________________________

Signature of participant if 18 or older: ______________________________________________