Permission Form
CISV-Smoky Mountain Chapter
For Overnight Junior Branch Activities

To whom it may Concern: 

I,  _____________________________________________, parent/legal guardian of
                       (Print name of parent/legal guardian)


 ______________________________________________________  the minor child at the local CISV program
                              (Print name of Child)
_______________________________________________ authorize adult chaperones of the
                                      (Name of CISV Event/Program)

CISV-Smoky Mountain Chapter to consent to or arrange for medical care and/or hospitalization, and to
determine and undertake such financial obligations as may be necessary in the event such services are
required from __________________________              to _______________________________ .

I understand every effort will be made to contact me in the event my child should require medical attention
of any kind.

A CISV participant is expected to conduct her/himself at all times in conformance with local laws and
CISV rules.

I also understand participants engaging in inappropriate behavior may be sent home before the end of
the CISV event or program listed above.

As proof of my consent in granting temporary guardian powers and in acceptance of the conditions noted
above, I have signed this document on    _________________ .
                                                                               date signed
________________________________
 Signature of Parent/Legal Guardian

Address:
____________________________________________________    City ____________   Zip _____________

Emergency Phone Numbers:
Home: ________________________

Work: ________________________

Other: ________________________ (Relation to Child: ___________________________ )

Beeper: _______________________

Cell Phone: ________________________

rev 11/27/01