TO:     Congresswoman Shelley Moore Capito
C/O Mary Elisabeth Eckerson
4815 MacCorkle Ave., SE
Charleston, WV 25304
Phone: 304.925.5964
Fax: 304.926.8912

Re: Parental Permission Form
I, _________________________ (parent name), hereby grant permission for my son/daughter, __________________ (student name), to participate in the 2010-2011 Student Advisory Committee sponsored by Congresswoman Shelley Moore Capito, WV-2.
Address:___________________________________________________________________
Phone:_____________________________________________________________________
Emergency Contact:___________________________________________________________
Email:______________________________________________________________________
Signature:___________________________________________________________________
Anticipated Schedule (subject to change):
    October 30,2010: Kick-off reception with Congresswoman Shelley Moore Capito
    February 13, 2010: Guest Speaker
    April 10, 2010: Guest Speaker
    May 22, 2010: Graduation and reception (parents invited to attend)
Please sign and return this form to the address listed above.  
For more information, visit www.capito.house.gov or contact my District Director, Mary Elisabeth Eckerson, at 304-925-5964.  
Sincerely,

Member of Congress