BAMN

510-502-9072
http://www.bamn.com
california@bamn.com

Coalition to Defend Affirmative Action & Integration

And Fight for Equality By Any Means Necessary
BAMN PARENTAL PERMISSION SLIP
STUDENT Information:
Name:______________________________________________________
Address:_____________________________________________________
Phone number: ____________________ Cell:_______________________
Date of Birth:__________________________________________________
Parent/Guardian Information:
Name of Parent or Guardian:________________________________________
Address:________________________________________________________
Home Phone:_____________ Cell:______________ Work:_______________
Relationship to Student:___________________________________________
In Case Of Emergency:
Emergency contact: Name:____________________________________
Address:__________________________________________________
Phone Number:____________________________________________
Relationship to Parent/Student:________________________________

Please list any health conditions, allergies or diet/mental/physical restrictions that your child may have and medications that
he/she may be using to treat this condition. Indicate if the child has your permission to take such medication while attending
the event. You may also include the name of the hospital or doctor of your choice and their phone numbers.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

PERMISSION NOTICE :

Students, Bring this with you on Thursday!

My son/daughter _____________________________________________ has my permission to attend the BAMN AGU

Town Hall: Building a Scientist and Student-Led Environmental Movement at the American Geophysical Union National
Conference of Scientists, in the Moscone Center in San Francisco. I hereby agree to indemnify and hold harmless and
blameless the Coalition to Defend Affirmative Action and Integration and Fight for Equality By Any Means Necessary
(BAMN), its officers, employees or agents from any and all liability from damages, loss or injuries, either to person or
property, which the said minor may sustain while engaged in any activity conducted by or in connection with BAMN
including but not limited to transportation. I further certify that I have legal custody by reason of the fact that I am the parent
or the legal guardian by court order. I further allege that the said minor is physically able to participate in the activity set
forth herein. I further agree in case of injury or illness or other actions requiring parental permission, BAMN staff shall have
the authority to act for me, in case I cannot be reached. I further understand that in case of injury, serious illness, or in
extreme cases of disciplinary action, the BAMN staff will, if need be, send home my son/daughter by the first available
transportation at my own expense.
________________________________________
PRINT Parent or Guardian Name
________________________________________
Parents or Guardians Signature
For more information, contact BAMN:

www.bamn.com

letters@bamn.com

510-501-2435