Parental permission slips - Suffern Free Library

Lock In Friday Night Permission Slip
Suffern Free Library
Questions? Call Kristie, Miguelina or Nancy at 357-1237
Participant Name: _______________________________
Age:_________Grade_______
Home Address:
__________________________________________________________
City, State, Zip: _____________________________________
Email: _____________________________________________
Home Phone: ________________________
Cell Phone: _________________________
Parent/Guardian Name:
_______________________________________________________
Emergency Phone #:
_______________________________________________________
Refreshments will be served. Please list any food allergies:
________________________________________________________

RULES OF CONDUCT
You will not be allowed to exit and re-enter the program. Once you check in at the
front door, you are to remain in the library until you are ready to leave FOR THE
EVENING.
The program ends promptly at 9:00 p.m. Please make sure that you are aware of
the time the event ends. While noise level rules will be more relaxed, standard
rules of library conduct still apply.
Rules of library conduct include but are not limited to:
Noisy or disruptive behavior
Threatening, offensive or abusive language and behavior
Harassment of employees or customers
Misuse or defacement of library facility or materials
Violating any state, federal or local law
I agree to comply with the rules for Lock-in Friday Night. I agree to listen to
library staff. I understand that Library employees are authorized to enforce these
rules. The Library reserves the right to revoke or restrict event privileges of any
user for conduct contrary to these rules.
Printed name:
Signature: ______________________________________________________________
Parent/Guardian Name & Contact Number: _________________________________
_______________________________________________________________________
CONSENT FORM AND LIABILITY WAIVER
I hereby give permission for _____________________ to attend the Lock In
Friday Night program. I assume all responsibility for injury to my child, and for
injury which my child may cause to others. I hereby release and forever
discharge Suffern Free Library, their officers, employees from any an all
damages and causes of action either at law or in equity which I or my child may
have as a result of participation in or attendance at this activity sponsored by
the library.
__________________________________ _______________
Signature of parent or guardian date

IN CASE OF MEDICAL EMERGENCY
I give permission for the supervising adults at Suffern Free Library to contact
911 for medical assistance for my child/ward named above, and consent to
medical treatment as deemed necessary by emergency medical personnel. I
will be contacted immediately if any emergency arises.
__________________________________ _______________
Signature of parent or guardian date
BEHAVIOR
My minor child/ward and I understand that violations of Suffern Free Library’s
appropriate behavior policy or the enjoyment of others at this event will result
in eviction. Parent/Guardian agrees to be available at one of the phone
numbers listed above the night of the lock-in. Or list the name and phone
number of an adult contact available to pick up child in case of emergency.
__________________________________ _______________
Signature of parent or guardian date