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___/___/___
