To be filled out by parents or legal guardians of participants under 18 years of age.

 

 

I, ________________________, the parent and/or legal guardian of __________________________, a minor child, hereby acknowledge that said child is presently under my care, custody and control. I hereby give said child my express permission to participate in/at ____________________________________________________________________________________________. I also give my permission to the Trinity Covenant Church  leaders, or its representatives, or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon said child, which may in their sole discretion be necessary and proper under the circumstances.

 

I, the undersigned parents and/or guardian of said child, do release, acquit, discharge, and covenant to hold harmless Trinity Covenant Church, it representatives, agents, servants, and employees from any and all actions, damages, or liabilities arising out of any sickness or injury incurred by said child in the above listed activity during the above dates or incurred in the treatment of any such sickness or injury.

 

I also hereby give my permission for the above named child to be transported to and from sponsored activities by authorized and licensed personnel or representatives of Trinity Covenant Church

 

I also understand that should my child present a severe behavioral problem or seriously violate any trip rules, I will be notified and arrangements will be made to send the child home.

Students Name________________________________________   Age  ___________        M/F

 

Parent and/or Guardian __________________________________________________________

 

Address ______________________________________________________________________

 

City _______________________________________________   State ____________________

 

Zip Code ________________________________    Phone (____) ________________________

 

Parent and/or Guardian Signature _____________________________  Date _____/_____/_____

 

Does your child have any special needs/disabilities that require extra adult supervision? If yes, please explain______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLEASE NOTE THAT IF YOUR CHILD REQUIRES ONE ON ONE SUPERVISION, YOU NEED TO MAKE ARRANGEMENTS FOR THAT SUPERVISION.

 

Please list any allergies: __________________________________________________________

 

______________________________________________________________________________

 

Doctor _____________________  City __________________             Phone (____) ____________

 

Do you have health insurance:         _____ YES           _____ NO      Policy name and number___________________

 

In emergency notify: __________________________            Phone (____) __________________

More details: