Youth Medical Release & Activity Permission 2018-2019
Youth Name
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First Name
Last Name
Parent Name
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First Name
Last Name
I give my permission for my child to participate in overnight and off-site activities with St. Paul's Youth Ministry. I understand that some of these activities involve travel in privately owned vehicles driven by adult volunteers or parish employees. I do hereby hold harmless and release St. Paul’s Episcopal Church, Cary, and all adult volunteers and employees from any liability in the event of any accident, injury, or loss of personal property involving my child during this activity.In the event of a medical emergency, I understand that every reasonable effort will be made to contact me at the phone numbers listed below. In the event that I am unable to make arrangements for emergency medical treatment for my child, I authorize any adult volunteer or parish employee associated with the Sunday School or Youth Group activity to consent to all necessary medical care in my absence. I also understand that payment for such services is my responsibility as the parent/legal guardian.
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Yes
No
Electronic Signature
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
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Area Code
Phone Number
Alternative Phone Number
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-
Area Code
Phone Number
Medical Insurance Company
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Contact for Authorization
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Policy Number
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Allergies, Medical Conditions, Restrictions, Special Needs:
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Any other information for adult leaders to know about your youth?
Submit
Should be Empty: