Crosswinds Church

Youth Permission Form

 

 

My child/children (names)*

 Has my expressed permission to attend the following event*

Date of the event* ...

Parent(s) Name*

Home Address*

City*

ST*

Zip*

Parent(s) Mobile Phone*

Parent(s) Email*

I understand that risk is involved anytime a group goes on a trip, whether local or away, and I willingly accept normal risk. If at any time during the event/trip my child becomes injured or sick, this is my expressed permission for my children listed on this form to receive medical attention and treatment from a qualified emergency team, nurse, or doctor. This includes permission for emergency surgery and/or medication if it is deemed necessary.*

Best Number to reach me at during the event

Family Physicians Name*

Physicians Phone Number*

Family Dentist*

Dentist Phone Number*

Health Insurance Company*

Policy Number*

My child has the following medical conditions that emergency medical personnel and others may need to know about (special conditions might include asthma, allergies, current medications, recent medical treatments/surgeries, etc.):

Signature of Parent/Legal Guardian*

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