YOUTH MINISTRY PERMISSION FORM
2010-2011
I hereby give my child, _________________________________________, permission to participate in all Youth Ministry activities, trips and programs, sponsored by County Line Church of Warm Springs from September 2010 – August 2011.
PARENT / GUARDIAN SIGNATURE: ____________________________________ DATE: ________________
General Information
Student’s Name:
______________________________________________________________ Date of Birth: ____/_____/_____Address:
___________________________________________________________________________________________________(Street) (City) (Zip)
Home Phone #:
______________________________________________ Student’s Cell #: ________________________________School Attending:
_______________________________________________________ Current Grade: ___________________Father’s Name:
__________________________________________________ Cell #: ____________________________________Mother’s Name
: _________________________________________________ Cell #: _____________________________________Medical / Emergency Information & Release
In the event my child becomes ill, is injured or requires emergency medical attention of any kind, and I cannot be reached by telephone, I hereby authorize the adult chaperon (s) to make the necessary decisions concerning emergency treatment. I also give permission for my child to be transported to the nearest medical facility or hospital for treatment.
PARENT / GUARDIAN SIGNATURE: ____________________________________ DATE: ________________
If a parent cannot be reached, please contact the emergency person listed below:
Contact: _________________________________________________________ Home Phone #: ___________________________
Cell #: _______________________________________ Relationship: ________________________________________________
My child wears
Contact Lens YES ______ NO ______My child’s last
Tetanus shot was on ___________________________________________________________Please list any
allergies to Medications your child has: (If NONE, check here _______)____________________________________________________________________________________________________________
Please list any
medications your child takes on a regular basis: (If NONE, check here _______)____________________________________________________________________________________________________________
Please list any other
health / physical information we should know about your child: (example: Asthma, Food Allergies, ADD/HD, etc.)____________________________________________________________________________________________________________
Child’s Physician’s Name: ________________________________________________ Office Phone #: _____________________
Medical Insurance Company: __________________________________________________ Phone #: _______________________
Policy #: ________________________________________________ Group #: __________________________________________