Youth Permission Slip

Please print out page and return to the church PRIOR to event departure
All information will be kept confidential.

Clique Aliança Para acessar o ministério de língua portuguesa

Event: ________________________________________________________________

Name of student: _________________________ Nickname: ____

Birthdate:  __/__/__    Grade in school: ____  SS#: ______-___-_____  

Home phone: ___________________ Work phone:__________________
Cell phone: ____________________Email:________________________

Parent/guardian name: ________________________________________

Address:________________________________________________________

Work phone: ______________________Cell phone:_________________

Parent email: ___________________________

Emergency contact names(s): ____________________________________

Address:_____________________________________________________

Home phone: ___________________Work phone: ______________________ Cell phone: ____________________

Insurance Information

Please fill out completely and include a copy of insurance card

Is the student covered by family medical/hospital insurance?    Yes/ No

If so, indicate carrier or plan name: ____________________________________

Group #____________________________  ID#__________________________

Carrier address:___________________________________________________________
Carrier phone #: ___________________________________________________

Name of insured: ___________________
Relationship to participant: ________________
Social Security # of policy holder or insurance ID#: __________________________

Immunization record - please attach

Permission to provide necessary treatment or medical care:

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the event adult leadership to administer treatment, including hospitalization, for the student named on the front of this form. My permission includes: x-rays; routine tests; treatment; release of any medical record necessary for medical or insurance purposes; administration of prescribed medications; necessary related transportation for the student. I understand payment for emergency care is the parent or guardian’s responsibility.

Signature of parent/guardian                                                                              date

Family Doctor Information

Name of physician: ____________________________
Phone #: ____________________
Address: _________________________________________________________

Name of dentist: ________________________Phone #: ____________________
Address: ________________________________________________________________

Name of orthodontist: ____________________________
Phone #: __________________
Address: ________________________________________________________________