Elementary Activities Permission Form

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What: A free twice a month activity -usually Bingo or Minute to Win It activities with snacks and prizes. Sponsored by the Clearwater Recreation Commission. Who: For kids ages K-3rd grades. Must have written/digital parental permission. Where: Elementary West in the Commons/Lunch Room When: typically, the 1st and 3rd Monday of the month during school time from 3:30-4:30pm

Child's Name*

First Last

Select Child's Grade Division*

Select way of dismissal:*

Parent/Guardian Name*

First Last

Parent/Guardian Work Phone Number*

Parent/Guardian Phone Number*

Permission for Photos to be taken?

Parent/Guardian Email*

Others allowed to pick up your child? Please state below their name & relationship.

Address*

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Signature*

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