AUTORIZZAZIONE DEI GENITORI I sottoscritti _______________________________________________________ e_________________________________________________________________ genitori del ragazzo________________ _______________________________________________ ___________________________________ nato/a a _____________________________ il ___________________________ e residente a ________________ in via___________________________, nr______ presa conoscenza del Metodo Educativo Scout, propo proposto sto dalla AGESCI – Associazione Guide uide E Scout Cattolici Italiani Italiani e dell'importanza pedagogica delle Campo Estive, autorizzano __l__ propri__ ragazz__ a partecipare al Campo Estive del Reparto “Mario Giuseppe Restivo”” del Gruppo Monreale 1 nella base scout Massariotta ssariotta - Marineo (PA) dal 29 Luglio al 07 agosto 2011 Data: _______________ Firma dei de genitori: ______________________________ ________________________ ______________________________ ________________________ Recapiti telefonici dei genitori durante il campo: campo:____________________________ ____________________________ __________________________________________________________________ __________________________________________________________________ ____________________________________________________________ __________________________________________________________________ ____________________________________________________________ __________________________________________________________________ SCHEDA MEDICA allegare alla al presente) Fotocopia codice fiscale e libretto sanitario del ragazzo/a (d’allegare Cognome___________________________Nome____________________________ Nato a__________________il________________ residente a _________________ Via ______________________________ Tel______________________________ Gruppo sanguigno _________ RH______ Vaccinazioni effettuate : (possibilmente possibilmente allegare fotocopia libretto vaccinazioni) vaccinazioni Antipolio / data _______ Antidifterica / data ________ Antivaiolosa / data_______ Antipertossica/data______ a______ Antiepatite B/data_______ Altre_________/data_____ Antitetanica / data ultimo richiamo ______________ Allergie a cibi, medicinali, altro:________________________________________ altro:________________________________________ __________________________________________________________________ _______________________________________________ __________________________________________________________________ _______________________________________________ __________________________________________________________________ Eventuali medicine da somministrare: somministrare:_____________________________________ _____________________________________ __________________________________________________________________ _______________________________________________ ___________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Altre notizie utili:_______________________________ _______________________________________ _____________________ __________________________________________________________________ _______________________________________________ __________________________________________________________________ _______________________________________________ __________________________________________________________________ _______________________________________________ _______________________________________________________ __________________________________________________________________ Nome e recapiti del medico di famiglia:___________________________________ __________________________________________________________________ Data: _______________ Firma dei de genitori: _____________________________ _________________________ ______________________________
Scarica
