Deca Permission Form printable pdf download

PENNSYLVANIA DECA

ATTENDANCE PERMISSION FORM

PLEASE NOTE: Three copies of this permission slip are needed--one for the advisor, one for the student,

and one for the PA DECA.

This is to certify that ____________________________________ has my permission to attend the

_________________________________________ held at the

______________________________________________ on _________________________________.

I also do hereby absolve and release school officials, the DECA Chapter Advisor or other responsible adult, and the

assigned DECA staff from any claims for personal injuries or illness that might be sustained while he/she is

traveling to and from or during the DECA sponsored activity.

Participant’s last name:

First name:

Street Address:

City:

State:

Zip:

Home telephone: (

)

Date of birth:

Grade:

School name:

Address:

School phone: (

)

City:

State:

Zip:

Parent/Guardian Name:

EMERGENCY INFORMATION

I/we authorize the DECA chapter advisor/responsible adult to secure the services of a physician or hospital

and to incur the expenses for necessary services in the event of accident or illness. I/we realize that I/we will be

responsible for the payment of these costs.

Name of emergency contact person:

Home telephone: (

)

Work Telephone: (

)

Family physician name:

Physician phone: (

)

Is the student taking any medication?

If yes, please list:

Please list any allergies, medical needs or health problems:

Insurance company name:

Insurance plan/group number:

We have read and agree to abide by the Pennsylvania DECA Rules and Regulations and Dress Code. We also

agree that the school officials, the DECA Chapter Advisor, the State DECA staff and the Conference Conduct

Committee have the right to investigate possible violations of the DECA Rules and Regulations and authorize the

search of the above named student’s room or property in furtherance of such an investigation. We also agree that the

school officials, the DECA Chapter Advisor, the State DECA Staff and the Conference Conduct Committee have the

right to send the above-named student home from the activity at the expense of the family provided that he/she has

violated the Rules and Regulations and/or his/her conduct has become a detriment. The expenses will include

transportation and other student expenses.

_____________________________ ______________ ___________________________ _____________

Student Signature

Date

Chapter Advisor Signature

Date

____________________________________ __________________ __________________________________ _________________

Parent/Guardian Signature

Date

School Official Signature

Date

Deca Permission Form

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