SAC Meetings Student Representation Permission Form

I give permission for my child (dates listed below) to attend monthly SAC meetings on the following dates:

This will give my child at least 1 hour of service credit per meeting for Junior National Honor Society.

_________________________________ (Signature of Parent/Guardian) __________________________ (Date)

IF YOU ARE INTERESTED IN ATTENDING SAC MEETINGS PLEASE INITIAL.

Please CLEARLY Print Information

Name of Child	______________________________________
Date of Birth	____________________
Name of Parent/Guardian	______________________________________________________________
Primary Phone Number	_______________________
Email	__________________________________
Secondary Phone Number	______________________________________________________________
Address	______________________________________________________________ ____________________________________________________________________
Alternate Contact Name	______________________________________________________________
Alternate Contact Phone Number	______________________________________________________________

How will your child get home after the meeting? PLEASE INITIAL ONE.

Notes are required from parents for change in transportation.

NOTE:

Are there any medical needs we need to be aware of? (Circle one) No Yes

If yes, please complete the “Medical Needs” section:

Medical Needs: (Please indicate if child is allergic to any foods, etc.)

__________________________________________________________________________________

_____ Please initial if you give your permission for Landrum SAC to use your child’s photograph for promotional purposes.

Your SAC Contact is: Mrs. Jayne Devine [email protected]

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