________________________ (name)
has my permission to go on the
________________________ (event)
on
______________ (date)
In the event my child becomes ill or is injured while under church supervision; I approve the sponsors taking the following steps:
Contact a parent or guardian of the young person and follow his instructions.
In the event that neither parent or guardian can be reached, contact the young persons’ physician and follow his/her instructions.
If the young persons’ physician cannot be reached, the sponsors will use their own judgement in contacting a properly licensed practicing physician and follow his/her instructions.
In the case my child is involved in an accident and requires treatment, the attending physician has my permission to examine and begin treatment in my absence.
I agree to relieve the church and youth group sponsors from any liability in connection with these activities and instructions.
________________________ (family doctor name)
________________________ (doctor phone)
________________________ (parents name)
________________________ (home phone)
________________________ (work phone)
________________________ (parents signature)
