|
YOUTH |
CLICK HERE FOR PERMISSION SLIP | |
|
AT WORK |
WHITEWATER RAFTING 2009 |
![]() ![]() |
![]() ![]() |
![]() |
![]() |
![]() |
![]() ![]() |
|
AT WORSHIP |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
|
AT PLAY |
|||
![]() |
![]() | ||
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
![]() |
|
AT CAMP IN DOWELLTOWN, TN. SUMMER 2007 | |
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
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 April 2010 – September 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 chaperone 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 #: __________________________________________