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
#__________________________