Annual Permission Slip
Annual Permission Slip Medical Information & Medical Care Release Instead of filling out individual forms for every program, activity, or outing, I/We acknowledge that we are filling out this form to be authoritative and in full effect for one full year, from January 1 through December 31, 2010. Check the appropriate ministry for which this form is applicable; multiple choices can be made: ___________ Children’s Ministry ___________ Sunday School ___________ Jr. High Youth Group ___________ Church Sponsored Outings ___________ Sr. High Youth Group Information About Child/Teenager: Name _____________________________________________________________________________ Address ___________________________________________________________________________ City _____________________________________ Zip Code _____________ Home Phone Number ____________________ Email: _____________________________ Father’s Work Number ___________________ Cell ______________________ Mother’s Work Number __________________ Cell _______________________ Person to Contact in the Event of and Emergency:Name _________________________________ Phone ______________________ School Grade as of January 1, 2010 ______________________________________ Birth date _________________ Age __________ Sex ( ) M ( ) F Currently lives with: ____ Both Parents _____ Mother ____Father _____ Legal Guardian Home Church _______________________________________________________________ Has your child been baptized by immersion? ( ) Yes ( ) No |
Medical Information
Insurance Company ______________________________________ Policy # ___________________________
Date of Last Tetanus __________________was it an initial or booster? _________
Does your child have penicillin or other drug reactions ( ) Yes ( ) No
If so to what ______________________________________________________________________________
Has your child been exposed to any disease with the last month? ( ) Yes ( ) No
If so to what ______________________________________________________________________________
Allergies? ( ) Yes ( ) No What?_____________________________________________________________
Is your child to be restricted in any way from strenuous games? ( ) Yes ( ) No
Explain __________________________________________________________________________________
Any special medication or diet which is to be continued? ( ) Yes ( ) No
If yes give complete instructions: ______________________________________________________________
Please provide any additional medical information you feel is pertinent to your child: ____________________________________________________________________________________________________________________________________________________________________________________
Permission Slip(I ) (We) (Parents) (Legal Guardians) do hereby give permission for (my) (our) child to participate in children and/or youth activities, including trips, outings, regular and special events, including such that require travel, and do herby release, indemnify and hold forever harmless First Christian Church of Pleasant Hill, California, and any paid and or volunteer representative of the Church, or their assigns, against loss from any and all claims, demands or actions in law ore in equity that may hereafter be made or brought by the said minor child or by anyone on behalf of said minor child for the purpose of enforcing a claim for damages on account of any injury, accident, or fatality incurred in consequence of any injury, accident or incident that may be sustained by said minor child en route to , during, or en route from any church-related activity which my child participates in.
I have read and understood this agreement.Parent or Legal Guardian_____________________________________ Date____________________________
Parent or Legal Guardian ____________________________________ Date____________________________
Medical Care Release(I) (We) (Parents) (Legal Guardian) of ____________________________________
do hereby authorize any paid or volunteer supervisory adult member of First Christian Church, Pleasant Hill CA as agents for the above minor child to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by any physician or surgeon licensed under the provisions of the Medical Practice Act.
It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent(s) to care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization will be effective up to and including December 31, 2010, unless sooner revoked in writing to said agent (s).
Parent or Legal Guardian_____________________________________ Date______________________________
Parent or Legal Guardian______________________________________ Date______________________________
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