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 #:  __________________________________________