Permission Slip

Basic Information:

Child Name: (First)______________________ (M.I.)____ (Last)_____________________

Child Age:________ Grade Currently Enrolled:_________________
Boys & Girls Club member? Yes___ No___

Put an X by the desired lesson session:

____Session A January-April
____Session B June-August
____Session C September-December

Circle the desired instrument:

(2nd-12th only) Keyboard (6th-12th only) Voice (6th-12th only) Acoustic Guitar

Please fill in the blanks:

I give permission for my child, _________________________, to receive music lessons from

Seeds of Sound for _________________ (instrument: voice, keyboard, acoustic guitar) by a
music instructor of the organizations choosing. I am aware of the nature of these activities. I
agree to hold harmless Seeds of Sound Volunteers, and all those associated with The Boys &
Girls Clubs of the Ocoee Region. I also do give my explicit permission to sponsoring adults to
administer first aid, and to seek further emergency medical treatment for my child deemed
necessary.

Emergency Contact Name:________________________________

Phone Number:_________________________________

Parent Signature:___________________________________ Date:___________