For
_____________________________ _______________
Name of Trip Date
I, the undersigned parent or guardian of_______________________(hereafter my child), give permission for my child to participate in the above North Wilkesboro Presbyterian Church Youth Group activity. I also authorize the adult leaders of the activity to authorize any necessary medical treatment for my child. I also release the North Wilkesboro Presbyterian Church and the adult leaders, advisors, and chaperones from all liability for any injuries, claims or damages related to the trip to the extent that their liability is not covered by insurance.
________________________
Parent
or Guardian
_______________________
Date
Child’s
Name:________________________
Age_____ Date of
Birth______________
Address:_______________________________________________________________
City State Zip
Phone #:_____________________ Emergency Phone #:_________________________
Social
Security #:_______________________________
Medications
(currently using):______________________________________________
Allergies
(food or medicine):_______________________________________________
Insurance
Company:______________________________________________________
Policy
Name or #:________________________________________________________
Family
Doctor:_________________________ Phone
#__________________________