Shadow Permission Form

*Applicant's First Name

*Applicant's Last Name

*Grade Applying For

Person Inquiring

*Relationship to Student

*First Name

*Last Name

*Mobile Phone

(ex. 555-555-1234)

*Email Address

Emergency Information: In the event of a medical emergency involving this student, I hereby authorize Gerstell Academy to take necessary measures to have this student treated. It is understood that treatment will be done only after all reasonable efforts have been made to contact this student's physician and parent/legal guardian.

*Please list any physical limitation or medical condition (including allergies and medications) that you would like us to be aware of. If none, please state 'none.'

*In case of emergency, please notify (type name)

*Best contact telephone number

*Electronic Signature of Parent/Guardian

*Date

2500 Old Westminster Pike
Finksburg, MD 21048-1823
410-861-3000
1-866-861-3300