Covenant Presbyterian Youth Connection
Permission – Release Form
Covenant Presbyterian
Church
(316) 722-7613
September 2007 – August 2008
Youth’s Name: __________________________________________________________
Address: ________________________________________________________________
Email Address: ___________________________________________________________
Phone: (hm) _______________ (wk) __________________ (cell) __________________
Age: ______________ Birthdate: ____________________ Grade: __________________
Parent/ Guardian: _________________________________________________________
Relationship to Youth:_____________________________________________________
Emergency Contact:
1. Name: _________________________________________________________
Phone Numbers: _________________________________________________
2. Name: _________________________________________________________
Phone Numbers: _________________________________________________
3. Name: _________________________________________________________
Phone Numbers: _________________________________________________
Additional information: ________________________________________________________________________
________________________________________________________________________
Health History:
Pre-existing or present medical condition: _____________________________________
________________________________________________________________________
_____________________________________________________________
Allergies: ________________________________________________________________________________________________________________________________________________
Major illness during the past year:
_______________________________________________________________________
Last Tetanus shot: __________________
Swimming Restrictions: ____________________________________________________
Activity Restrictions: ______________________________________________________
Any other important medical information:
________________________________________________________________________
I
hereby give permission for my child/dependent to attend and participate in
Covenant Presbyterian Church’s events. The undersigned hereby gives permission
for the minor to ride in any vehicle designated by the adult in whose care the
minor has been entrusted while attending and participating in activities
sponsored by the Youth Ministries programs at Covenant. In the event of an accident every attempt
will be made to contact immediately the persons listed on this form. In the
event I cannot be reached in an emergency, I authorize an adult, in whose care
the minor has been entrusted, to consent to medical, surgical, or dental
diagnosis and/or treatment and hospital care, to be rendered to the minor on
the advice of a licensed physician or dentist. I shall be liable and agree to
pay all costs and expenses incurred in connection with such medical and dental
services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for my child to return home due to medical reasons or
otherwise from a long- distance outing, the undersigned shall assume all
transportation costs.
I understand all reasonable
safety precautions will be taken at all times by Covenant Presbyterian Church
and its agents during events and activities. I understand the possibility of
risk. I agree not to hold Covenant Presbyterian Church, its leaders, employees,
or volunteers staff liable for damages, losses, diseases, or injuries incurred
by the student of this form.
Hospital Insurance: ________Yes ________No
Insurance Company:_______________________________________________________
Policy #: ________________________________________________________________
In Whose Name is the Insurance?: ____________________________________________
Family Doctor: ____________________________ Phone: ________________________
I grant permission to Covenant Presbyterian Church to post my child’s photograph on the church’s website. Yes__________ No ____________
Parent/Guardian Signature: __________________________________ Date: __________