PERMISSION FORMMikeMike212009-02-16T04:22:00Z2009-02-16T04:22:00Z13772149Toshiba175252111.5604

PERMISSION FORM

FIRST BAPTIST CHURCH HELOTES

ACTIVITY OR TRIP-- ____________________________________________________DATE OF ACTIVITY OR TRIP -- ___________________________________________**********************************************************************************

PARENT’S/GUARDIAN’S WAIVER

(If Participant is under 18 years of age)

I, as parent or guardian of____________________________________, am willing and desirous

{NAME OF PARTICIPANT}that my son, daughter, or ward, participate in the event referred to above. In consideration of the benefits to be derived from said event or activity, I hereby voluntarily waiver any damage or loss to person or property which may be directly or indirectly sustained in the above named activity. It is understood that this release shall be binding upon myself, my assigns, my personal representatives and heirs.SIGNATURE_________________________________________DATE__________________

{PARENT OR GUARDIAN}

ADDRESS___________________________________________________________________PHONE (HOME)______________(WORK)______________(EMERGENCY)_____________TRANSPORTATION from event other then parent or guardian: _________________________***********************************************************************************

MEDICAL RELEASE FORM

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SEX: M F

AGE:________

This will authorize medical and surgical treatment, as needed,

for my child by physician chosen by the youth minister/sponsor of this church.

PARENT(S) SIGNATURE:________________________________________

HOME PHONE NO._______________________________

BUSINESS PHONE NO._________________________________________

Other Person to notify in case of emergency: NAME:______________________________________

PHONE NO._____________________

NAME OF YOUR INSURANCE COMPANY:_____________________________________________

PHONE NO.__________________________

POLICY NO.______________________________________

NAME OF INSURED:________________________________

MEDICATIONS NOW BEING TAKEN?

______________________________________

_______________________________________

ALLERGIES:____________________________________________________________________________

_______________________________________________________________________________________************************************************************************************