Permission Slip

________________________________ (name of participant)  is hereby Granted Permission to participate in the ___________________________(event), to be held on _____________(Date)

 at _________________________________________(Location) . 

I also authorize the bearer of this note to act on my behalf  and  approve appropriate treatment on my behalf should emergency medical treatment be necessary.

My child is allergic to _____________________________                                                         _

(list any allergies to medication, food, or other substance)

My child is currently taking the following medications _________________________________

Medical Insurance Company___________________ and Policy Number:__________________

Family Doctor Name: ___________________________________________________

I Hereby  release from any liability Faith United Methodist Church and all adult sponsors or church staff in the event of any accident enroute, during, and returning from the above event. 

Date: _____________________ Parent/Guardian Signature:____________________________             

Phone number where parent/guardian may be reached during the event: ___________________

Permission Slip

________________________________ (name of participant)  is hereby Granted Permission to participate in the ___________________________(event), to be held on _____________(Date)

 at _________________________________________(Location) . 

I also authorize the bearer of this note to act on my behalf  and  approve appropriate treatment on my behalf should emergency medical treatment be necessary.

My child is allergic to ____________________________                                                         __      

(list any allergies to medication, food, or other substance)

My child is currently taking the following medications _________________________________

Medical Insurance Company___________________ and Policy Number:__________________

Family Doctor Name: ___________________________________________________

I Hereby  release from any liability Faith United Methodist Church and all adult sponsors or church staff in the event of any accident enroute, during, and returning from the above event. 

Date: _____________________ Parent/Guardian Signature:____________________________             

Phone number where parent/guardian may be reached during the event: ___________________