WEST GOSHEN TOWNSHIP
PARENTAL/GUARDIAN PERMISSION FORM

Name of Participant(s) Under 18 Years of Age:_______________________________

__________________________________________________________________

Address:___________________________________________________________

Chaperone Accompanying Child(ren):_____________________________________

Recreation Activity and Date: December 10, 2011 Bus Trip to New York City

I, the undersigned, as legal guardian for the participant(s) listed above, grant
permission for participation in the aforementioned event. The chaperone listed
above assumes responsibility for the listed child(ren) during the event.

____________________________       ____________________________
   Signature of Parent or Guardian                     Date

____________________________
     Signature of Chaperone
 (if different from parent or guardian)