PTA 8th Grade Dance 2022 - Payment and Consent Form | Myra S. Barnes Intermediate School 24

PTA 8th Grade Dance Payment and Consent Form

Parent/Guardian & Student must complete this form together. If you select online payment, you should have your credit card information ready as you will be prompted to enter payment information at the bottom of the consent form. Please read each section of the form carefully and fill in all required fields. You will have the option at the bottom to pay online OR to send in cash or money order. EVERYONE must fill out this permission form.

Please fill all the information out to the best of your ablilty so that the PTA chaperones have anything they might need to assist your child on the evening of the dance. We have included important information for the dance below.

Dance Information:

Location: Nicotra's Ballroom at the Hilton Garden Inn

Time: 5pm-8pm

Cost: $80

We will provide more information regarding arrival and dismissal proceedures when we get closer to the date.

Please note, if you have any questions or concerns, feel free to email the PTA president Laura Sannicandro at [email protected].

Student's Last Name*

Answer Required

Student's First Name*

Answer Required

Parents/Guardians

Please review & answer the following questions carefully. If an item does not apply to your child, please reply "none".

I understand that there are risks of injury associated with the above physical activities and I consent to my child's participation in all activities except for the following (please list if any):*

Answer Required

Please indicate below any permanent or temporary medical or other condition, including special dietary and medication needs, or the need for visual or auditory aids, which should be known about your child:*

Answer Required

I agree that in the event of an emergency, injury or illness, the volunteers in charge of the dance may act on my behalf and at my expense in obtaining medical treatment for my child.*

Answer Required

Yes

I understand that I am responsible for getting my child to and from the departure and return site (The Hilton Garden Inn). I understand that my child shall be accompanied by staff member(s) during the event.*

Answer Required

Yes

YOUR Full Name (Parent or Guardian) *

Answer Required

Address*

Answer Required

Cell Phone (The one you carry with you)*

Answer Required

YOUR Email Address*

Answer Required

What is your relationship to the student?*

Answer Required

What is your daytime emergency phone number? *

Answer Required

What is your evening emergency phone number?*

Answer Required

STUDENT Cell Phone Number*

Answer Required

Additional Emergency Contact - Full Name*

Answer Required

Additional Emergency Contact - Cell Phone Number*

Answer Required

Additional Emergency Contact - Day/Evening Phone*

Answer Required

Name of person who will drop my child off at the dance.*

Answer Required

Name of person who will pick my child up from the dance. *

Answer Required

Food Allergies

Does your child have any food allergies or medical conditions that we should be aware of at the dance?*

Answer Required

Yes

If you answered "yes" above, please list any food allergies or medical conditions we need to know about during the dance. If there are none, please type "none" in the space provided.*

Answer Required

Restriction of Contact

Please review & answer the following questions carefully. If nothing applies to your child, please reply "none".

Is there person(s) who may not be in contact with your child? *

Answer Required

Yes

Name of person(s) who may not be in contact with the student who is named in this document. Indicate "none" if applicable.*

Answer Required

Permission for PTA Dance

I give my child permission to participate in this event.*

Answer Required

Yes

By typing my name below, I am electronically signing this consent form for the PTA I.S. 24 event described in this document.

I am the parent/guardian in this form, I am not the student/child completing this form.
I am acknowledging that any misbehavior by my child at the dance will be shared with school administration.

Type your full name below (as an electronic signature).*

Answer Required

Today's Date.*

Answer Required

Payment Options

Answer Required

$80.00 - Online Payment

$0.00 - I will send $80 cash or money order (payable to I.S. 24 PTA) in to school with my child.

We cannot wait to celebrate the end of your school year with you!

The I. S. 24 PTA

Please fix the highlighted areas below before submitting.

PTA 8th Grade Dance 2022 - Payment and Consent Form