Church Street Church of Christ

Permission / Emergency Form

Name: 

Address: 

Parent’s / Guardians’ Name: 

Address: 

Home Phone:  Work Phone: 

Notify in Emergency (Other than Parent/Guardian):

Name:   Phone: 

Address: 

Name of Insurance Company: 

Policy Number: 

            As parent or guardian, I hereby give my approval and consent for ______________ to attend Church Street Church of Christ youth activities from 7/1/07 to 7/1/08. In consideration thereof, I hereby relieve Church Street Church of Christ and all adult chaperons on the trip my child is attending from any and all liability for sickness, accidents or injuries of any nature or cause whatsoever while attending, coming to or leaving this trip.  In case of an emergency illness of my child demanding immediate attention by a doctor to save his/her life, and the adult chaperons could not reach me by phone, I give my consent for the group leader in charge and/or adult chaperons to authorize the doctor to do what he/she deems necessary to save the child’s life.

                                                                                      ___________________

 Signature of Parent/Guardian                                           Date

  Other information/comments: