Amby presents: Kimeldorf's Grandfriends Project -- Sample Permission Slip



Sample Permission Slip

[School Letterhead]

[Date]

Dear Parents or Guardians:

Our school district is building partnerships with local individuals and businesses in our community to provide unique training opportunities for our students. If you would like your son/daughter to participate in our community based learning experiences, which involves travel off campus, then you need to furnish information on the following items and return this form with your signature.

Sincerely,

[Staff Member's Signature]

[Request information which is helpful to have on hand.]

Student Name
Birth Date
School
Grade
Home Address
Parent/Guardian Name
Home Phone
Parent/Guardian Address
Work/Day Phone
Updated medical information about any condition the student has or medications being taken.

[Ask the parent or guardian to sign a permission statement.]
I hereby grant permission for my son/daughter to participate in the community/school job training opportunities of the _____________________ School District for the school year 19___/19___.

__________________________________		__________________
(Parent/Guardian Signature)		(Date)

[Clarify the insurance or liability options]
Please read the following statement and provide your signature below:

I understand that accident insurance is not a requirement for participation in the ____________________________________ School District's community based training program. I recognize that in case of injury to my son/daughter, the cost of treatment is my responsibility and not the School District or community site.

Please check one or more as it applies to you.

I have insurance coverage for my son/daughter with:

__________________________________		__________________
Medical Coverage		Policy Number
__________________________________		__________________
Dental Coverage		Policy Number

I accept full responsibility for the cost of treatment for any injury my child may suffer while participating in the school's program.

I have purchased the school insurance program as outlined in the brochure included with this form.

__________________________________		__________________
(Parent/Guardian Signature)		(Date)

APPENDIX E-SAMPLE PHOTO PERMISSION FORM

[School Letterhead]

[Date]

Dear Parents:

From time to time the District desires pictures of students in our educational programs. We would like to have your written permission for the District to photograph/video tape and to identify your child for possible use in school related activities. Thank you for your cooperation.

Sincerely,

[Staff Member's Signature]

PLEASE RETURN TO YOUR CHILD'S TEACHER

I give my permission for my son's/daughter's photograph/video tape and/or name to be used for school related activities.

__ Yes __ No

Student's Name _____________________________________(Please Print)

Parent's Signature __________________________________

Date ___________________

Martin Kimeldorf, *author* kimeldorf@amby.com	© 1999 *All Rights Reserved.*	Amby Duncan-Carr,*page designer* webmaster@amby.com
Material from both THE GRANDFRIENDS PROJECT, A Program Creating Friendships Across The Generations and the companion piece, PROJECT LEADER'S GUIDE FOR THE GRANDFRIENDS PROJECT, A Program Creating Friendships Across The Generations is reproduced here with the permission of the publisher, Fairview Press. Printing or downloading a single copy of this document for personal use is permitted; teachers may reproduce this document for use in a single classroom, only. Transmission in any form or further duplication is prohibited without the express written consent of the author. In addition, any use of the document code, itself, requires the written permission of the web page designer.