Permission Form

 

 

 

 

 

I give permission for to take part in the following activity:

                                        First                  Last

 

 

Time:

 

Illness of any kind:

                                                            (Asthma, Diabetes, ETC)

 

Allergies:

                                       (Food, Drug, ETC.)

Presently Taking any Medications              Yes              No

If yes, What Kind?

 

In case of emergency I can be reached at the following number:

If I cannot be reached Please Contact:(name and number) 

                                                                                      

 

I hereby give my consent for counselors to administer First Aid and/or place my child in a doctor's care if necessary.

 

In signing this form, I release and hold harmless Faith Baptist Church and all of its representatives of any liability resulting from any injury which may occur while participating in the activity listed above. This includes the time spent while traveling to and from said Activity.

 

___________________________                    _______________________

 (legal guardian's signature)                                     (Date)