Interact 5510: Fall Leadership Conference

PARENTAL CONSENT STATEMENT FOR FALL LEADERSHIP CONFERENCE

I give my consent for my son/daughter to attend the Interact Rotaract Conference. I understand that Rotary District 5510 has liability insurance. I understand that there will not be an on-site medical person and that the participant will be responsible for bringing his/her own medication. I authorize the Interact or Rotarian chair to contact me to initiate medical care and to pick up my son/daughter.

To the best of my knowledge, my son/daughter is in good health, and I give my permission for attendance at this retreat and to participate in activities. I understand that males and females will be in classes together.

I also understand that my son or daughter will be responsible for his or her own transportation to and from A.S.U. Every attempt will be made by adult Rotarians to organize carpools for the students.

The responsible person for this event will be the District 5510 Interact Chair, Chris LaBarge. She can be reached at: 480-229-0150 cell.

Student Information

Student's name:

 

Interact club:

 

Sponsoring Rotary Club:

 

Student's cell phone:

 

Student's email:

 

Home address:

 

Parent Information

Parent's name:

 

Emergency contact phone:

 

2nd Emergency contact phone:

 

Enter Security Code: