Autorisation parentale 11-13 ans

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Je soussigné(e), Madame, Monsieur :…………………………………………………………………………………..

Demeurant au : ………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………….

et agissant en qualité de (rayer les mentions inutiles)                  Père            Mère         Tuteur

Autorise (rayer les mentions inutiles)                                              mon fils           ma fille

et demeurant à la même adresse (ou une autre si elle est différente)

……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….

à quitter seul l’Espace jeunes * à partir de 17h30.

*Dès que le jeune sort de l’enceinte de l’Espace jeunes, il n’est plus sous la responsabilité du Foyer, mais sous celle de ses parents.

Je certifie avoir l’autorité parentale sur cet enfant.

Date :                                             Signature du parent :

 

 

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