Chicago Trip Permission Slip

Youth's Name (Last)

Youth Name (First)

DOB

Address

Street Address Line 2

City

Full Name of Parent(s) or Guardian

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Emergency Contact: In the event that the primary guardian cannot be reached:

(Name)

Emergency Contact

Phone Number

Emergency ContactFormat: (000) 000-0000.

Insurance Carrier

Policy No.

Family Doctor (Name)

(Phone)

Format: (000) 000-0000.

Medical facts requiring special attention (Medications, Sleep issues, etc)

Allergies

Other Concerns

Medication

List MedicationTime to administer

YesNo

PARENT/GUARDIAN SIGNATURE

Date

The powers granted to above said Life coaches, Mentors and Sponsors are limited to the following.

*TO seek medical care for the youth, including, but not limited to, visits to the doctor, and/or hospital.

*To authorize medical treatment or medical procedures in the event of an emergency situation.

*To provide food and shelter for the above named youth, and to make decisions regarding their safety on the trip.

*To transport children on chartered bus transportation.

I/we understand that reasonable precaution will be taken to safeguard my child’s social and mental well being during this field trip (boat ride, amusement park ride, Travel around Chicago, hotel stay, eating, and activities while we are in Chicago as are taken in all other New B.O.Y. sessions. The Chicago field trip will take place from Sat, Oct 21, 2023, leaving from the IBNB Center and will conclude Sunday, Oct 22, 2023. If you have any questions pertaining to the trip: please call Kareem Hines at 317-869-5022.

I/we will not hold Inner Beauty Program, Inc., New B.O.Y., The Indiana Department of Child Service, MC Juvenile Probation, Child Advocates, the Mentors, nor various school districts, liable for any concerns or unfortunate mishaps that may occur during this mentoring trip. This grant of authority is effective as of 10/21/23, and shall remain in effect until 10/22/23.