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I give permission for my above-named child to join the ____________________________ group of Trinity United Methodist Church for the __________ ______________ activity at/to __________________________ on the date(s) of ____________________ . I understand that the group will be traveling via _______________ . I also understand that the cost of $__ . includes _______________________________________________ . This cost does not include ________________________________________________ , I am paying by: cash check # _____.
Special Instructions are:
I hereby release Trinity United Methodist Church, its staff and supporters from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any X-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible.
Signature of Natural Parent or Legal Guardian _________________________________
Date _____________________ Emergency Phone Number
MEDICAL INFORMATION (Required for Overnights)
ALLERGIES
MEDICATIONS BEING TAKEN
PHYSICAL HANDICAPS OR LIMITATIONS
MEDICAL INSURANCE COMPANY
POLICY NUMBER MEMBERS NAME
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