Community Options:

Date:

I, ____________________ give ________________(client) permission to participate in:

(Please initial in blank)

_____ Extra curricular activities at school

_____ School sponsored field trips

_____ Out of state trips (specify) ________________

_____ Organized sports

_____ Horseback riding

_____4 wheel driving

_____ Swimming

_____ Boating

_____ Adanta sponsored outings

_____ Ropes course

_____ Other (specify) ________________________________

________________________________

________________________________

Guardian Name: ______________________

Address: ____________________________

____________________________

Witness: ____________________________