8/14/2019 Mysteries: A Masquerade Prom April 4, 2009 Prom Guest

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Empire Academy presents

Mysteries: A MasqueradeProm

April 4, 2009 Prom Guest Permission Slip

I give permission for my child, ______________________, to attend Empire Academys2009 Prom at the Seascape Golf Club in Aptos. I understand that Prom is from 7:00 pmto 12:00 am, that my child needs to stay on site at all times, and that there are no in andouts. This is a formal event, and your child should be dressed appropriately. As always,Empire Academy events are drug and alcohol free. If it is suspected that your child isunder the influence of any substance, they will be asked to leave, and you will be calledto come pick them up.

Please indicate which dinner choice your child would like:

_____ Chicken Piccata _____ Tri-Tip _____ Pasta with Fresh Vegetables

Please indicate how your child will be leaving:

____ I will pick up my child at ______ a.m. after the prom.____ My child will get a ride home from _____________________ after the prom.____ My child will be going to ________________ with ________________ after the prom.

(place) (name)

In case of emergency, I can be contacted at the following numbers during prom:

1st number______________________ Alternate number:________________________

Parent: Please Call Sinda Merritt, Director of Empire Academy, at 458-4200 and

authorize your childs attendance. Your child will be unable to attend without

this authorization phone call.

In the event of an apparent or real emergency in which medical treatment or hospitalization of my child may be necessary, theundersigned parent or guardian does hereby authorize and appoint Empire Academy, through its agents, to obtain any medical

treatment or hospitalization of the above named child as they believe necessary and proper for the immediate care and welfare of said

child. I do further authorize and direct any medical doctor or hospital to render any and all treatment believed necessary and proper

for the immediate care and welfare of the above named child and the undersigned agrees to pay for such medical treatment and

expenses incurred on behalf of such child and shall hold Empire Academy and its agents harmless from any and all liability, claims,judgments and costs incurred in or as a result of any such medical treatment or hospitalization.

Signed:____________________________________ Date:_________________________

Please sign and return this form with $60, which covers dinner, Prompictures and casino games by March 9th. Make checks payable to SEA. If

you have any questions, please feel free to call 458-4200.