|
Activity Permission Slip
October 14, 2009
(I) (We), the undersigned
parent(s)/Guardian(s) of ___________________________(Print Name) grant
permission for the above named minor to attend the Lakewood United Methodist Church
(UMC) Youth-directed activities. (I) (We) understand that the Youth
Leader, Lisa Karle, will enforce reasonable safety precautions.
However, in the event of an accident or injury to the above named minor, I will
not hold the Lakewood UMC responsible. It is understood that neither
the Lakewood UMC nor the Youth Leader may provide medical insurance coverage
and that (I) (We) will be responsible for any or all medical expenses
incurred by the above named minor.
It is also understood that
(I) (We) authorize the Youth Leader to act as an agent of the undersigned, to
consent to any professional transportation (i.e. ambulance), X-ray
examination, anesthetic, medical/surgical diagnosis or treatment and hospital
care which is deemed advisable by, and to be rendered from, a licensed
physician or surgeon. The authorization will remain in effect for the
duration listed above, or until revoked by (Me) (Us), the undersigned
parent(s)/guardian(s).
Event: Event Date & Time:
Address:
Phone:
Lisa’s Cell: (814) 397-0591 Cost:
Printed Parent/Guardian Name:_______________________Signature:_______________________
Minor Signature: __________________________________Minor
Cell Phone:_________________
Minor Address:_______________________________________Phone:_______________________
Youth Leader Signature: ______________________________Date:_______________
Emergency Contact:_____________________________________Phone:____________________
Allergies:
___________________________________________________________________________
Medication:
_________________________________________________________________________
Physician:_____________________Address:___________________________Phone:______________
Insurance Company
Name____________________________Phone:___________________________
Insurance Group#_________________________Insurance
ID#_________________________________
|