Youth Event Permission Slip


I certify that I am the parent/legal guardian authorized to give permission on this form.
I hereby give permission for my child to participate in the event listed below.
My child and I are aware of and understand that participating in any church trip, event or activity may be potentially hazardous due to circumstances such as (but not limited to) falls, contact with other participants, the effects of weather, traffic, and other reasonable risk conditions associated with this activity.
By submitting this form, I assume all risks associated with participation in this trip, event or activity.

Event/Activity

Event/Activity Date (YYYY-MM-DD)

Youth First & Last Name (required)

Age

Grade

Youth Street Address

Address Line 2

City

State

Zip Code

Youth's Cell Phone #

Youth's Email Address

EMERGENCY INFORMATION:

Parent/Guardian First & Last Name (required)

Parent/Guardian Email (required)

Parent/Guardian Home Phone (required)

Parent/Guardian Cell Phone (required)

Alternative Emergency Contact First & Last Name (required)

Phone for Alternative Emergency Contact (required)

Family Physician

Health Insurance Provider

Policy Number

Allergies or Dietary Restrictions

Medications

Other Needs/Information

PERMISSION FORM

This youth has my permission for the following (check all that apply):
Ride in the car with a Youth Group Adult Sponsor
Ride in the car with another member of the Youth Group that is licensed to drive

As the parent/legal guardian of the listed youth, I hereby authorize any necessary hospital care or medical and surgical procedures to be performed for my child by a licensed physician or hospital when deemed necessary or advisable by a physician to safeguard my child's health in the event that I cannot be contacted. I waive my right of informed consent for such treatment.

Parent/Guardian signature (required)

By typing my name and submitting this form I certify that I am the parent or legal guardian of the Youth listed on this form.