Permission form

NAME:_________________________________________________________________

 

ADDRESS:______________________________________________________________

 

PARENTS’/GUARDIANS’ NAME:__________________________________________

 

ADDRESS:______________________________________________________________

 

HOME PHONE:______________________ WORK PHONE:_____________________

 

NOTIFY IN EMERGENCY (OTHER THAN PARENT/GUARDIAN)

 

__________________________________________ PHONE:______________________

 

ADDRESS:______________________________________________________________

 

NAME OF INSURANCE COMPANY:________________________________________

 

POLICY NO:____________________________________________________________

 

 

 

As parent or guardian, I hereby give my approval and consent for ___________________

_________________________ to attend _______________________________________

from _____________________ to ____________________. In consideration thereof, I hereby relieve Crieve Hall Church of Christ and all adult chaperons on said trip my child is attending from any and all liability for sickness, accidents or injuries of any nature or cause whatsoever while attending, coming to or leaving said trip. In case of an emergency illness of my child demanding immediate attention by a doctor to save his/her life, and the adult chaperons could not reach me by phone, I give my consent for the group leader in charge and/or adult chaperons to authorize the doctor to do what he/she deems necessary to save the child’s life.

 

 

___________________________________________

Signature of Parent/Guardian

 

___________________________________________

Date

(Copy and paste this form into a Word document to print off for an event.)