Sample Guardian Consent Letter For Travel & Emergency

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GUARDIAN CONSENT LETTER FOR TRAVEL & EMERGENCY
To Whom It May Concern:
This is to confirm that my child, __________________________, will participate in one or more NUSEA events in
the 2014-2015 program year (June 1, 2014 – May 31, 2015) and will be under the supervision of NUSEA’s coaches,
staff members and volunteers.
In the event of an emergency, I grant permission and do authorize NUSEA coaches, staff members and volunteers to
make any necessary decisions regarding my child’s welfare and medical condition. Should there be any need, I can
be contacted at the phone number(s) listed below.
Sincerely,
_______________________________ Date: _____________
____________________________________
(Signature of Parent/Guardian)
(Print name of Parent/Guardian)
---------------------------------------------------------------------------------------------------------------------------------------------
Phone (h) _______________________ Phone (w) _____________________ Phone (c) ____________________
Additional Parent/Guardian Cell ____________________ If parents/guardian cannot be reached, please contact:
Non-Parent Contact: ______________________________________ Phone: ______________________________
Health Insurance Company or Policy Name: _______________________________
Policy/ID #: ___________________________ Group #___________________________________
Does your child have allergies or regularly take medication? If yes, please describe:
____________________________________________________________________________________
Does your child have permission to swim during NUSEA activities? YES NO
Can your child swim in the deep end of a pool? YES NO
555 Eighth Avenue • Suite 1102 • New York • NY • 10018 • 718-280-9340 (t) •
 

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