OVERNIGHT ADVENTURE PROGRAM AUTHORIZATION FORM FOR PROGRAM PARTICIPATION AND OVERNIGHT STAY ABOARD THE USS SALEM

I ______________________________________(parent or guardian’s name) hereby give permission for my son/daughter ___________________________(name) to participate in the Overnight Adventure program aboard the USS SALEM at the United States Naval Shipbuilding Museum. I further grant permission for the United States Naval Shipbuilding Museum Overnight Adventure program staff to arrange for emergency medical care for my son/daughter in the event that they are injured during their participation in the Overnight Adventure program. I further understand that my son/daughter must behave properly and in accordance with the instructions of the Overnight Adventure program staff and that I may be required to retrieve my son/daughter from such program in the event that they fail to properly behave.

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NAME RELATIONSHIP TO CHILD

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FULL ADDRESS SIGNATURE

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E-Mail Address DATE

EMERGENCY PHONE NUMBERS IF I CANNOT BE REACHED,

PLEASE CONTACT:

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HOME NAME

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WORK OR OTHER TELEPHONE NUMBER

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MEDICAL INS. COVERAGE RELATIONSHIP TO CHILD

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MEDICAL INS. POLICE NO.

PERTINENT MEDICAL INFORMATION (FOOD OR DRUG ALLERGIES, ETC.)

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