[SCHOOL NAME] [Club Name] Permission Slip | Return by [Month DD, YYYY] |
[Club name] meets after school for students in grades [N]–[N]. [One or two sentences on what the club does.] Please complete every section and return this form to [advisor name] in room [Room].
1 Schedule
DAYS [Tuesdays and Thursdays] | TIME [3:15]–[4:30] p.m. | LOCATION [Room or area] |
DATES [Start date] to [end date] | ADVISOR [Name] | CONTACT [Phone or email] |
COST $[Amount] or free | SNACK [Provided / bring your own] | NO CLUB ON [Dates or early-release days] |
2 Pickup arrangements
At the end of each session, my child will:
□ Be picked up by a parent or guardian □ Be picked up by an adult listed below | □ Walk or bike home (grades [N]+ only) □ Ride the activity bus, route [N] |
Students not picked up by [00:00] will wait in [location], and families will be contacted.
ADULTS AUTHORIZED FOR PICKUP | RELATIONSHIP | PHONE |
|---|---|---|
3 Emergency contacts and health
CONTACT | RELATIONSHIP | PHONE | ALTERNATE PHONE |
|---|---|---|---|
Allergies, medical conditions, or medications
4 Consent
I give permission for my child to take part in [club name] on the schedule above. I understand the pickup arrangements and will tell the advisor in writing if they change.
Student name Grade / teacher
Parent / guardian name Phone
Parent / guardian signature Date