Carrollton First UMC Event Permission Form

Event Permission Form

To Whom it May Concern
name of child/youth* has my permission to go with the name of group on the following event event name at location of event on date of event
Parent/Guardian signature

Clear
Date

Month Day Year
Date
Emergency Contact Name: *

First Name Last Name
Phone number in case of emergency *
Alternate contact in case parent(s)/guardian cannot be reached *

First Name Last Name
Alternate contact's phone number *
Medical/Health Information
Allergies, medicine, hay fever, insect bites, asthma, food, other:
Other pertinent health information:
Does your child/youth have any conditions that would prevent him/her from fully participating in this program? If yes, please explain:
List medication to be taken during the event which will be kept by the leaders during event:
Preferred Doctor
Phone Number
Please enter a valid phone number.
Preferred Dentist
Phone Number
Please enter a valid phone number.
Preferred Eye Doctor
Phone Number
Please enter a valid phone number.
Preferred Hospital
Phone Number
Please enter a valid phone number.
Emergency Medical Authorization

I give my consent for emergency medical treatment by a certified first aider. In the event that additional treatment is needed, the staff of the Emergency Room of the hospital listed above, or one closest to the event location, has my permission to treat my child/youth.
Parent/Guardian Signature

Clear
Date

Month Day Year
Date
Parent/Guardian Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Hospitalization Plan and Group #
Should be Empty:

Event Permission Form

Medical/Health Information

Emergency Medical Authorization