(Fill in all fields then select all and print)

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I give permission for to take part in the following activity:

                                           (Child's Full Name)

 

 

Date/Dates: To

 

 

Medical Information

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Illness of any kind:

                                                                                (Asthma, etc.)

 

Allergies:             

                                                                                (Food, Drug, etc.)

 

Presently taking any Medication?      Yes                 No

 

If yes, what kind?

 

 

Emergency Contact Information

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In case of Accident I may be reached at:

 

                                                                                              

Permission

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I hereby give my consent for counselors to administer First Aid and/or place my child in a doctor's care if necessary.

 

I give my permission for counselors in charge to be able to take necessary measures if my child disobeys.

 

In signing this form, I release Innerarity Point Baptist Church and it's representatives from any and all liability in the event of an accident.

 

______________________________                 _______________

  (Parent's Signature)                                               (Date)