Self-Healing Permission Slip
Complete this form to grant permission for participation in self-healing activities.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you the participant or a guardian?
*
Participant (18+)
Parent/Guardian (if under 18)
Name of Parent/Guardian (if participant is under 18)
Self-Healing Activity Description
*
Date of Activity
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any relevant medical conditions or allergies
Signature
*
Submit Permission Slip
Submit Permission Slip
Should be Empty: