2026 Swimming Permission Slip Form
This form grants permission for your child to attend our swimming trips this summer. Please note, this does NOT guarantee spots on all of the swimming days. Daily sign up is still required. This form is active for all of summer 2026.
Member Information
Member Full Name
*
First Name
Last Name
Member Number
Child's Gender
*
Male
Female
Other
Member Date of Birth
*
-
Month
-
Day
Year
Date
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
Emergency Contacts
Emergency Contact 1 Full Name
*
First Name
Last Name
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 1 Relationship
*
Emergency Contact 2 Full Name
*
First Name
Last Name
Emergency Contact 2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact 2 Relationship
*
Medical Information
Medications
Enter "None" if not applicable
Allergies or Other Medical Conditions
Enter "None" if not applicable
Chronic or Recurring Illnesses/Diseases
Enter "None" if not applicable
Activities to be Restricted (if any)
Enter "None" if not applicable
Medical Authorization & Agreement
This health history is correct so far as I know, and the person herein described has permission to engage in all club activities, except as noted by be or the examining physician. In the event of an EMERGENCY, I hereby give permission to the Physician selected by the Boys & Girls Club staff and volunteer to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for the person herein described.
*
I agree
I disagree
Signature & Acknowledgement
By submitting this form, I confirm that all information provided is true, complete, and accurate to the best of my knowledge. I understand that submission of this form does not guarantee placement in any field trip and that participation is subject to availability and Boys & Girls Club policies. I acknowledge that payment has been submitted for any field trips requiring a fee, if applicable, and understand that my child’s participation may be contingent upon receipt of payment. I agree to all terms outlined in this form and provide my electronic signature as authorization for my child’s participation.
Parent/Guardian Signature
*
Submit Permission Slip
Submit Permission Slip
Should be Empty: