Northeastern School District

300 High Street, Manchester, PA 17345

Dear Parent/Guardian:

Your child will be attending NE Mini-THON from 9 am to 5 pm on May 5, 2012. In order to attend Mini-THON a minimum donation of $35 must be collected. It is suggested that Mini-THON participants collect money from family and friends. Attached is a sponsor sheet to be used for this purpose.

In order for your child to attend, you will need to give your permission. Also, in order to provide the needed medical care in the event of an emergency, you are asked to authorize the supervising adult to sign a medical release.

By signing this form, you are doing the following three things:

1. Acknowledging your awareness of the event, and

2. Permitting a chaperone to make decisions concerning any immediate emergency medical treatment for your child, should such a need arise. (Without this written permission, it is unlikely that any hospital/physician would treat your child unless you were there to grant permission in person.)

3. Releasing Northeastern School District from any liability or responsibility for any incidents that occur during the NE Mini-THON event or in transit to and from the event.

Please sign this form below, detach, and return it to the school. NO child will be permitted to attend a school function without prior approval. Thank you for your cooperation.

PLEASE NOTE FOR CHECKS: Checks should be made payable to Northeastern High School with Mini-Thon in the memo line.

NE Mini-THON Permission Form

I give permission for my child, (please print child’s name) ________________________, to attend NE Mini-THON from 9 am to 5 pm on May 5, 2012. In the event that my child should require immediate emergency medical treatment while at this event and parent(s)/guardian(s) cannot be contacted, I give NE Mini-THON chaperones permission to authorize any immediate emergency medical treatment necessary for my child’s health and well-being. In order to provide appropriate medical care, please complete:

Chronic Medical Condition/Allergy __________________________________________

Treatment Required _____________________________________________________

Physician Prescribed Daily Medication at Home/School ___________________________

(Name)

____________________________________________________________________

(Dose) (Time)

ÿ My child should receive medicine at prescribed time.

ÿ My child should not receive this medicine at NE Mini-THON.

Signed: __________________________________________________________________________

(Parent/Guardian)

Signed: __________________________________________________________________________

(Student)

Address: __________________________________________________________________________

(Street) (City) (Zip)

Home Phone Number: _____________ Mother (C) ______________ Father (C) _____________

Date: __________________