Permission Release Form - Brush Creek Baptist Church - North Carolina printable pdf download

PERMISSION RELEASE

(Please Print)

Child’s Name___________________________________ Home Phone: ___________________

Address ______________________________________________________________________

Parent(s) Name ________________________________________________________________

As parent or legal guardian of the above-named child, I give my permission for my child to join the

group from Brush Creek Baptist Church for the following activity:

______________________________________

on this date:__________________________

I hereby release the church, Brush Creek Baptist Church, its staff and sponsors from responsibility

and liability for any injury or illness or death that my child may sustain during this activity. In the

event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent

to any x-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised

and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the law

of the state where the services are rendered, either at a doctor’s office on in any hospital.

I expect to be contacted as soon as possible if there are any problems, medical or behavioral, with

the above-named child during this activity.

(Please note: Your child will be expected to behave and to be courteous to all students, teachers and

other persons at all times. If your child will not comply, then he/she will be taken home.)

Signature of Parent or Legal Guardian ______________________________________________

Date: _____________________ Emergency Phone Numbers: ___________________________

___________________________

Medical Information (Use reverse side if needed)

Allergies _______________________________________

Medication being taken ___________________________

Physical disabilities or limitations __________________________________

Medical Insurance Company ______________________________________

Policy Number _________________________________________________

Member’s Name _______________________________________________

Brush Creek Baptist Church, 5345 Airport Rd., Bear Creek, NC 27207 — (919) 742-3221

Permission Release Form - Brush Creek Baptist Church - North Carolina