Midrealm Page School Authorization Form

MIDDLE KINGDOM PAGE SCHOOL AUTHORIZATION TRACKING FORM

Arts/Sciences

Service

Chivalry

PARTICIPANT’S COPY

KEEP THIS COPY FOR YOUR RECORDS

PROVIDE ALL INFORMATION REQUESTED BELOW (PLEASE PRINT LEGIBLY AND FILL OUT BOTH HALVES OF THIS FORM)

SCA NAME	DATE			PLEASE INDICATE LEVEL BELOW
FULL MODERN NAME	EVENT			JUNIOR PAGE
STREET ADDRESS				SENIOR PAGE
CITY	STATE/PROV		POSTAL CODE	GRADUATE PAGE
TELEPHONE	EMAIL ADDRESS			DATE OF BIRTH


NAME OF ACTIVITY (BE SPECIFIC)		ACTIVITY LOCATION			NUMBER OF ACCREDITED HOURS




TEACHER SIGNATURE			TEACHER SIGNATURE (IF MORE THAN ONE CLASS)

Created: 1/03

– – – – – – – – – – – – – – – – – – – – – – – – – – – <SEPARATE FORMS HERE> – – – – – – – – – – – – – – – – – – – – – – – – – –

MIDDLE KINGDOM PAGE SCHOOL TRACKING FORM

Arts/Science

Service

Chivalry

DEAN OF THE PAGE SCHOOL’S COPY

SEND THIS FORM TO THE DEAN OF THE PAGE SCHOOL

PROVIDE ALL INFORMATION REQUESTED BELOW (PLEASE PRINT LEGIBLY AND FILL OUT BOTH HALVES OF THIS FORM)

SCA NAME	DATE			PLEASE INDICATE LEVEL BELOW
FULL MODERN NAME	EVENT			JUNIOR PAGE
STREET ADDRESS				SENIOR PAGE
CITY	STATE/PROV		POSTAL CODE	GRADUATE PAGE
TELEPHONE	EMAIL ADDRESS			DATE OF BIRTH


NAME OF ACTIVITY (BE SPECIFIC)		ACTIVITY LOCATION			NUMBER OF ACCREDITED HOURS




TEACHER SIGNATURE			TEACHER SIGNATURE (IF MORE THAN ONE CLASS)

INSTRUCTIONS:

Give the participant this whole, completed form.

Created 1/03