"Travel and Activity Authorization Form"

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TRAVEL AND ACTIVITY AUTHORIZATION
10 NCAC 3U .0604(1)
Blanket permission for this activity
G. S. 110-91(6)
REV 8/92
Special 1-time permission only
Blanket permission for all given activities
SAMPLE FORM
I, _________________________________
________________________ parent/guardian of
name of parent/guardian
__________________________________________________________________________give my permission to
name of child
_____________________________________________________________________for my child to participate in the
name of
following activities
facility
Trips in the van/automobile (facility or parent-owned)
___________________________________________________________________________
Explain planned activity — where and when
Field trips away from the facility
____________________________________________________________________________
Explain planned activity — where and when
I
understand
that
the
facility
will
use
the
appropriate
child
restraint
devises
and
abide
by
all
the
safety rules in Rule .1000 when my child is transported in a vehicle. The facility will also notify me each time that my child is to
participate in an activity that would involve transportation.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
In addition, if the facility has planned activities outside the fenced area of the facility,
_______ I will allow my child to play outside the fenced area; or
_______ I will not allow my child to play outside the fenced area.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
File in child's folder
TRAVEL AND ACTIVITY AUTHORIZATION
10 NCAC 3U .0604(1)
Blanket permission for this activity
G. S. 110-91(6)
REV 8/92
Special 1-time permission only
Blanket permission for all given activities
SAMPLE FORM
I, _________________________________
________________________ parent/guardian of
name of parent/guardian
__________________________________________________________________________give my permission to
name of child
_____________________________________________________________________for my child to participate in the
name of
following activities
facility
Trips in the van/automobile (facility or parent-owned)
___________________________________________________________________________
Explain planned activity — where and when
Field trips away from the facility
____________________________________________________________________________
Explain planned activity — where and when
I
understand
that
the
facility
will
use
the
appropriate
child
restraint
devises
and
abide
by
all
the
safety rules in Rule .1000 when my child is transported in a vehicle. The facility will also notify me each time that my child is to
participate in an activity that would involve transportation.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
In addition, if the facility has planned activities outside the fenced area of the facility,
_______ I will allow my child to play outside the fenced area; or
_______ I will not allow my child to play outside the fenced area.
_________________________________________
Parent/Guardian Signature
_______________________________________________________
Date Signed
This authorization is valid from ______/______/______ to ______/______/______
File in child's folder