Asbury Cafe Youth Work Permission
     
 
Name
 
Address
 
Phone
 
I Confirm ...
My child is at least 12 years of age.
My child will be accompanied by a parent or sponsor.
Name:
 
My child will get to and from the cafe ...
 
Medical Release In the event of an emergency where medical treatment is required I give my permission to the Asbury Cafe Day Manager or other adult cafe worker or sponsor to obtain the services of a licensed physician. Please attempt to notify me immediately concerning any such emergency.
 
 
Hospital
 
Special Concerns

 

 

 
Signed
Date