About Us

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Bethany Presbyterian Church, Grants Pass

Permission & Emergency Medical/Contact Information for Children and Youth Activities

Child/Youth name: _______________________________________________

(Last)  (First)   (M.I.)

Birthdate: __________________

Address: ____________________________________________________________

Street, City, State, Zip

Home Phone: __________________________________

Parent(s)/Custodial Adult(s)’ Name(s): ____________________________________

Parent(s)/Custodial Adult(s) Phone numbers:

Work phone(s): _____________________ _____________________

Cell phone(s): ______________________ ______________________

In case of emergency contact:

1)  Name:____________________________ Daytime phone: ___________________

Relationship:_______________________ Evening phone: ____________________

Name and phone number of primary treating physician:

Allergies (including medications child/youth can NOT take) / Special Health Concerns:

Medical Insurance Company: __________________________________Policy #_______________

As the parent(s) or custodial adult(s) of ____________________________, I/we give permission for him/her to participate in the Cellphone Scavenger Hunt on Sunday, Oct. 28, 2018.   

I/we give permission to Bethany Presbyterian Church, its agents, staff, and volunteers to obtain urgent or emergency medical care for my/our child, and I/we authorize health care providers to render such care as may be necessary. It is understood that reasonable efforts will be made to contact me/us prior to obtaining such care, but I/we authorize such care whether I/we are contacted or not, and I/we agree to be financially responsible for such care.

I realize and accept that in the event of my child’s behavior adversely affecting the safety of the activity, the organizers reserve the right to return my child home. 

Name ________________________ Signature _________________________ Date___/___/___