Pawnee Nation Education Division
YOUTH SUMMER CAMP – August 3rd – 7th
Permission Slip

Youth Information (PLEASE PRINT):

Name: ______

Tribe(s): ______Enrolled: Yes/No

Roll Number: ______

School: ______

Date of Birth: ______Grade: ______

If not available in an emergency, please notify:

Name Relationship Phone

Name Relationship Phone

Authorized pick-up people are (including parents):

______

List of Allergies (please specific):

______

In the event of an emergency and someone not listed must pick up your child, please call (918) 762-3227 and inform the Youth Services Coordinator – Christina Goodson. Please do not send anyone to pick up your youth not listed and without notifying us.

Consent for Participation

I, ______parent/guardian of the above named youth, consent to my youth participating in the Youth Summer Camp 2015 (August 3-7) with the Pawnee Nation Education Division.

I agree that my youth’s participation in this camp is purely voluntary. I agree not to hold the Pawnee Nation Education Division liable or responsible for any loss or injury sustained by my youth arising in connection with his/her participation in this camp. I understand the camp has a no bullying policy and can enforce the consequence as staff sees fit. I understand I am responsible for providing transportation to and from camp at the designated time and locations.

Signature of Parent/Guardian: ______

Date: ______

Contact information (please specify) :______

Consent for Photographs

Except where a signature is required, please PRINT all requested information.

I, the undersigned parent, consent to my youth ______, attending the Youth Summer Camp (August 3-7) to being photographed. I agree that the Pawnee Nation Education Division shall have the right, but not the obligation to use my child’s photograph taken during this camp for their website at any time and for any other purpose or materials the Pawnee Nation Education Division deems necessary. The youth’s name will not be used with the photos.

Printed Name of Parent/Guardian: ______

Signature of Parent/Guardian: ______

Date: ______