Studio 12 Huntsville Activity Parental Permission Form

Studio 12 Huntsville - Parental or Guardian Permission and Medical Release

For: Friday Evening December 30, 2011 - 7:30 pm to Saturday Morning December 31, 2011 - 7:30 am - All Night Teen New Years Lock-In Party.

(Name of Participant): ______________________________________________ (Date of Birth): _________________

(Participants Parent or Guardian): __________________________________________________________________

(Address): ___________________________________________________________________________________

____________________________________________________________________________________________

(Phone): ________________________ (Email): _______________________________________________________

(Alt. Contact Information):________________________________________________________________________

____________________________________________________________________________________________

Medical Information

Does the participant have any of the following:

oSpecial Diet

oAllergies

oMedication

oChronic/Recurring Illness

oSurgery in past year or physical limitations

If yes, please explain below (use back if more space is needed) ____________________________________________

____________________________________________________________________________________________

I hereby give permission for my child/youth to participate in this activity.

Signed: __________________________________________________ Dated: ______________________________