Event Permission Slip

TEENS GROWING IN CHRIST
EVENT PERMISSION SLIP

(Please print this form off and fill in with all the information needed.)

Event Attending:__________________________________

Teen Name:_____________________________________

Birthdate:_______________________  Age: ___________

Address:________________________________________

________________________________________________

Parent/Guardian Names:____________________________

Emergency Phone Numbers: (name, number, relationship)

1. __________________________________________
2. __________________________________________
3. __________________________________________
4. __________________________________________

Physical Impairment/Allergies:

________________________________________________

________________________________________________

________________________________________________

Insurance Company & Policy Number:

________________________________________________

MEDICAL TREATMENT:

As a parent and/or legal guardian of the above named minor, I hereby give my consent for treatment by a qualified and licensed medical doctor in the event of a medical emergency which in the opinion of the attending physician may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort, if delayed. This consent is granted in the event that all reasonable attempts to contact me at the above listed phone numbers have been unsuccessful or in the case that I am unable to immediately come to be with minor named above. I will be responsible for all medical claims.

Signed: ___________________________________________

Printed:___________________________________________

Date:_____________________________________________

Relationship to Teen:________________________________