If the second parent/guardian lives in a different household, please provide the address information below:

 

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Emergency and Medical Information

 

 

 

 

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I give my child permission to go to the Walled Lake Outdoor Education Center (WLOEC) with Temple Shir Shalom.

I understand that transportation will be provided by school bus between Temple and the (WLOEC). In case of an emergency and I am unable to be reached, I give Temple Shir Shalom the authorization to act on my behalf for the care or treatment of my son/daughter.

PARENT:

1. My child has no physical or emotional problems which may be aggravated by events unless mentioned above.
2. The health history is correct as far as I know and the person herein described has my permission to engage in all planned activities, except as noted on this form.
3. In the event of a medical emergency, I give permission to the physician selected by the temple staff to secure proper treatment for my child as named above. We agree to pay any and all charges which may result from such treatment.