Field Trip Permission Slip - Ladies Of Leadership

Permission is given to Ladies of Leadership (L.O.L.) Summer Enrichment Reading Program for my
child(ren) to accompany L.O.L. staff and/or volunteers to any and all scheduled/planned field trips and/or
outings during the program (June 6 th , – July 29 th , 2022).

Parent/Guardian Name:

Parent/Guardian Mailing Address

Parent Phone #

Child(ren) Name:

Please select which option is required action in the event of accident or emergency.

(OPTION 1) In the event of accident or emergency, when a parent/guardian is unavailable, I hereby authorize a representative of Ladies of Leadership (L.O.L.) to make such arrangements as he/she considers necessary for my child to receive medical/hospital care, including necessary transportation. Under such circumstances, I further authorize the Physician named below to undertake such care and treatment of my child as he/she considers necessary. In the event that said Physician is not available at any time, I authorize such care and treatment to be performed by licensed Physician or surgeon. THE UNDERSIGNED PARENT/GUARDIAN FULLY UNDERSTANDS HE/SHE IS RESPONSIBLE TO PAY ALL COSTS INCURRED AS RESULT OF THE FOREGOING.

Physicians Name:

Medical Insurance

Medical Alerts: (Write N/A if not applicable)

Physician’s Phone#

Insurance Policy #

(OPTION 2) I do not choose the above statement and desire the following action to be taken:

I agree to hold L.O.L. Mentors and volunteers harmless for any accidents or injury that my child may receive by their voluntary participation in this fieldtrip.

Date

Comment