Permission Form

 

All Saints Episcopal Church – Youth Registration/Permission Form

 

I give permission for my child ______________________________________________ to participate in the activity listed below which is hosted by All Saints Episcopal Church. My child will be asked to behave and conduct themselves in a courteous and respectful manner with other participants, as well as adult advisors/chaperones.

 

I understand participants will be supervised and understand that the staff and volunteers of All Saints Episcopal Church and The Good Earth Farm are not responsible in the event of accidental injury or illness, nor for the compounded injury or illness to the participant’s present medical conditions which are listed below. I further understand in case of serious injury or illness I will be notified at the numbers listed below. If I cannot be contacted, I give my permission to the attending physician to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery for the participant as named above.

 

I also give permission to All Saints Episcopal Church to use photographs, voice and video images of the participant named below and photographs, voice and video images of any activities in which the participant is involved in any and all public awareness programs of St. Luke’s Episcopal Church.

 

Activity/Date: The Good Earth Farm Mission Trip - June 28 to July 2, 2011

 

Parent/Guardian Signature _______________________________________ Date_______________

 

­­­­­­­­­­Child’s Name_____________________________________________________

 

Address __________________________________________________________

 

Home Phone __________________   Gender ______    Date of Birth _________________

 

Parent Name ________________________________________           

 

     Home Phone ____________________

 

     Cell Phone ______________________

 

 

Parent Name ________________________________________           

 

     Home Phone ____________________

 

     Cell Phone ______________________

 

 

 

Other Contact _____________________________   

 

     Home Phone _________________

 

Relationship  _____________________           

 

Cell Phone ______________________

 

Physician’s Name ___________________________________           

 

     Phone __________________________

 

Dentist’s Name _____________________________________           

 

      Phone __________________________

 

List on back any current medical conditions or special needs that require medications, treatments, special restrictions or considerations:

 

And then Sign _________________________________ Date _____________