Please return this form by Sunday 5/21/17
For further information or concerns, call (312) 816-1320
Hyde Park Constellations
Permission for off campus activities

I hereby grant permission for my child ___________________________  (age) ________
Address: ________________________________ Apt # ______________
City ______________________________ State _____________ Zip ____________
Phone ____________________________
to attend the activity listed below:
Hyde Park Constellations Annual Camping Skills Weekend at The Environmental Learning Center,
Will County Forest Preserve, 20851 S. Briarwood Lane, Mokena, IL 60448 (Cleveland Road
Drop off Date & Time:       Friday 6/16/17 at 4:00pm          
Location:                           Hyde Park SDA Church, 4608 S. Drexel
Pick up Date & Time:        Sunday 6/18/17 5:30pm
Location:                           Cubesmart Storage 407 E 25th St. 60616
Fee:                                    Please be current with dues!
If you are dropping off your child, be sure to sign the waiver before leaving or your child
will not be able to participate.
Permission for transportation: In the event where the club provides transportation, I consent for my
child to be transported to and/or from the above stated activities.  The vehicle may/may not be
owned by the person driving it.  
Medical Consent:

In the event I cannot be reached in an emergency, I hereby give permission to the physician
selected by Verdell Williamson-Porter, Director or adult designee in charge, to hospitalize, secure
proper anesthesia, or to order injection or surgery for my child/ward.
Health Information:
Allergies ______________________________________________________________
Medications ___________________________________________________________
Last Tetanus ___________________________________________________________
Special concerns/conditions ______________________________________________
Please send all medications including inhalers with your child and be sure to inform the director/club
staff member in charge.

_________________________________________                ____________________
Parent/Guardian Signature                                                       Date

Phone number you can be reached at _____________________________________
Alternate number _____________________________________________________
Name (if other than yourself)  ___________________________________________