Permission Slip And Medical Release Form printable pdf download

Permission Slip And Medical Release Form

Heritage Baptist Church

2234 Utica Road – Lebanon, Ohio - 45036

PERMISSION SLIP and MEDICAL RELEASE FORM

Event: __________________________________________________________________

Date: ____/____/____

Participant's Name: ______________________________________________________

Street Address: __________________________________________________________

City: ___________________________________________________________________

Zip:__________

Current Grade: ___________

Date of Birth: ____/____/____

I hereby grant permission for my child to participate in the named above activity of

Heritage Baptist Church. I understand that my child participates in this activity at their

own risk and that Heritage and its adult leaders are not liable for any injury, personal or

otherwise, to my child or caused by my child. Should any problems arise concerning the

behavior of my child that would require them to return home prior to the end of the

activity, I will pay for his or her return or come pick my child up.

I recognize that Heritage uses photographs and video images of events in our publicity

materials such as the church website and Facebook and, I hereby grant permission for

photo/video images of my child to be taken and used for such purposes.

I authorize the treatment, by qualified and licensed medical personnel, of the minor

listed above in the event of any medical emergency which, in the opinion of the

attending physician, is necessary and I/we cannot be reached after reasonable effort has

been made to secure my personal consent.

Signed (parent or legal guardian):

________________________________________________________________________

Date: ____/____/____

Best Phone to Reach Me: (____)_____________________

Secondary Phone Number: (____)_____________________

Permission Slip And Medical Release Form