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Parent/Sponsor/Liaison Forms
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2009 SPU Retreat Forms
Event Permission Forms
*YOUTH NAME
*DOB
*AGE
*Address
*Special Medications/Needs
*GUARDIAN/PARENT NAME:
Parent Contact Number Home:
*Parent Cell Phone
Parent Work Number
*EMERGENCY CONTACT: Name ~ Address~ Phone
*I am registering for:
-Select a choice-
All SPU Events on March 21, 2009
Kick Tobacco Day Carnival
Camp Preston Hunt Lock In
March in Little Rock
Annual Youth Training Summer 2009
2008 STOMP OUT Oct 16, 2008
Central Mall Lock in
Regional New Year Lock In (Nashville, AR)
All SPU Events
De Queen Prevention Day April 4
SPU Life Development Training, April 17, 2009
Scout-A-Roma April 18, 2009
TEEN SUMMIT April 25, 2009
Special Notes about Youth: Allergies
PARENT NOTIFICATION
THIS IS A HIGH ENERGY, FUN, POSITIVE INITIATIVE THAT EMPOWERS YOUR CHILDREN TO MAKE HEALTHY LIFE CHOICES AND GIVES THEM THE TOOLS TO RESIST HIGH-RISK BEHAVIOR AND ACTIVITIES.
WE ARE SENDING OUT THIS NOTIFICATION LETTER TO YOU BECAUSE WE HONOR THE FACT THAT YOU ARE THE PRIMARY HEALTH EDUCATORS OF YOUR CHILDREN AND WANT TO INFORM YOU OF THIS EXCITING PROGRAM WHICH IS EMPOWERING TEENS TO RESIST PEER PRESSURE IN DAY’S TIMES.
AGAIN, WE KNOW THAT IS YOUR DESIRE TO TEACH YOUR TEENAGER HOW TO BE HEALTHY AND HOW TO HAVE A GREAT FUTURE. IT IS OUR INTENTION TO SUPPORT YOU IN THAT EFFORT.
IF YOU HAVE ANY QUESTIONS REGARDING THE PROGRAM TONYA DOMOKOS, MS, BEAT TOBACCO CONTROL PROJECT DIRECTOR AT 870-779-6048 OR 903-691-9421.
PARENT QUESTION REQUEST SLIP
I, THE UNDERSIGNED, DO HEREBY RELEASE THE SPECIAL PREVENTION PROGRAM, REGION 10 PREVENTION TASKFORCE AND VOLUNTEER STAFF, FROM ALL LIABILITY AND CLAIMS FOR ACCIDENTS, DAMAGES OR INJURY DURING TRAVEL AND/OR OTHER ACTIVITIES THAT MAY OCCUR WHILE MY CHILD IS ATTENDING ANY AND ALL EVENTS HOSTED BY THE SPECIAL PREVENTION YOUTH LEADERSHIP DEVELOPMENT GROUP AND THE REGION 10 PREVENTION TASKFORCE. I ALSO AUTHORIZE ANY MEDICAL ASSISTANCE THAT MAY BE REQUIRED FOR THE ABOVE NAMED CHILD DURING MY ABSENCE.
Parent Electronic Signature:
PLEASE PROVIDE THE FOLLOWING (OR A PHOTOCOPY OF MEDICAL INSURANCE CARD)
*MEDICAL INSURANCE COMPANY NAME
MEDICAL INSURANCE IDENTIFICATION NUMBER
*MEDICAL INSURANCE SUBSCRIBER’S NAME
MEDICAL INSURANCE GROUP NUMBER
*MEDICAL INSURANCE TELEPHONE NUMBER:
GOOD GRIEF!! WHAT SHALL I TAKE???
CLOTHING: SUGGESTED ITEMS
• TEES/JEANS NO SHORTS OR SHIRTS WITH OUT SLEEEVES!
• TENNIS SHOES
• JOG/SWEAT SETS
• SLEEPWEAR
PERSONAL:
• TOOTH BRUSH, TOOTH PASTE
• HAIR BRUSH/COMB
BRING YOUR SLEEPING BAG, BLANKET AND PILLOW!
OPTIONAL:
• CAMERA AND FILM (INEXPENSIVE)
• PERSONAL SNACKS FOR THE TRIP
IMPORTANT!!
THE SPECIAL PREVENTION UNIT WILL NOT BE RESPONSIBLE FOR DAMAGED OR STOLEN PROPERTY.
To Download Forms Click Here
Code of Conduct
FOR MORE INFORMATION ABOUT THIS EVENT
CLICK HERE