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Victory Jam Permssion Form 2010

This permission form allows a child to attend a beach trip and provides contact information for parents and emergency contacts in case of illness or injury. It gives the church adults accompanying the trip permission to seek medical treatment if needed and lists any known medical conditions or medications.

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chipmafia
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101 views

Victory Jam Permssion Form 2010

This permission form allows a child to attend a beach trip and provides contact information for parents and emergency contacts in case of illness or injury. It gives the church adults accompanying the trip permission to seek medical treatment if needed and lists any known medical conditions or medications.

Uploaded by

chipmafia
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Victory Jam 2010 Parent Permission Form

I, ___________________________________________, hereby give permission for


__________________________________________ to participate in the beach trip to
Harvey Cedars, New Jersey. In the event my child becomes ill or injured, I authorize the
accompanying church adults to take the following action:

1. Contact a parent of the minor and follow his/her instructions.


Home Phone #: ____________________________
FATHER'S NAME:__________________________
Fathers Cell Phone #: _______________________
MOTHER'S NAME:_________________________
Mothers Cell Phone #: ______________________

2. If parent(s) is/are unavailable, please contact the following person(s):


NAME:__________________________________
RELATIONSHIP:__________________________
HOME PHONE:___________________________
BUS. PHONE:____________________________

3. If no one can be reached in the event of an EMERGENCY, I hereby give my permission to


the physician selected by the youth leader to hospitalize, secure proper treatment for,
and to order injection, anesthesia for surgery to my child.

4. Known Medical Conditions and Drug Reaction:


_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

5. Medical Insurance Carrier:__________________________________________________


Policy#:___________________________________________________________________

Carrier:___________________________________________________________________

Policy#:___________________________________________________________________

Will your child be taking any medications while at camp?


_________________________________________________________________________

If yes, who will be in charge of the medicine? Check one


__________ The student
__________ A counselor with our group, NAME:___________________________________
__________ The Camp Nurse, INSTRUCTIONS:__________________________________

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