Fill out completely and fax or mail to Kids Repair Program at the address below Parent/Guardian Permission Form
(Please Print clearly)_______________________________________
Child's Name | ____________________
Nick-Name | ___________________________________________________________
Parent/Guardian's Name | _______________________________________
Address | ____________________
Apt | ________________________
City | _____________
State | ____________________
Zip | (____) - _______ - _______
Phone | _____________
Birthday | Male ____ Female ____ | ______________________________________
School | ____________________
Grade |
In case of emergency, if I cannot be reached, please contact: | 1. | ____________________________________
Name: | ____________________
Phone: | | 2. | ____________________________________
Name: | ____________________
Phone: |
I would like my child to participate in the Kids Repair Program. I will not hold responsible any person or agency connected with the program for loss or harm, including injury to my child during his/her participation in this program. Kids Repair Progrm has permission to use my child's photo in videos and publications, for the purpose of advertising and promoting the Kids Repair Program. (circle one) YES NO My child has been diagnosed by a doctor to have: (Please circle all that apply)
____ |
Attention Deficit Disorder |
____ |
Dyslexia |
____ |
Vision Problems |
____ |
Hearing Problems |
____ |
Other (please explain): ___________________________________ |
My child needs to take the following medication: ______________________________ Other special attention needed: _____________________________________________ | ____________________________________ | ___________________ | | Parent/Guardian signature | Date |
--------------------------------FOR OFFICE USE ONLY--------------------------------| Approved by: ___________________________ | Starting Date: ____________ | | Bicycle Make: __________________________ | Model: _________________ | | Helmet: YES NO | Lock: YES NO |
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 | KIDS REPAIR PROGRAM
208 MUSEUM DRIVE
LANSING, MI 48933-1912
(517) 485-8956
(517) 485-8125 FAX
Email to: Curt 'Grandad' Eure
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Brief Overview
