Immanuel Baptist Church Parental Permission Authorization Form printable pdf download

Immanuel Baptist Church

PARENTAL PERMISSION AUTHORIZATION FORM

Event Name: God and Guys Weekend

Place: Camp Paquette

Date: Feb. 10-12

Participant Name: ____________________________________________

Birth date: ___________________

I give permission for my child to attend the Immanuel event listed above.

Medical Release

I hereby request and authorize the Immanuel youth group, the Immanuel Baptist Church (IBC) of Pace, Florida, hospitals,

licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and

to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of

my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or

treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed

under the Medical Practice Act or dentist licensed under the Dental Practice Act for my child.

Custody Release

I further authorize the Director of Youth Ministries or a designated adult representative of Immanuel to receive physical custody

of my child upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody

of my child to said adult.

Activity Release

I further give permission for my child to participate in all supervised activities except as noted:

______________________________________________________________________________

__________________________________ ________________________ ________________

Signature of Parent or Legal Guardian

Printed name of Parent or Guardian

Date

Emergency Contact:________________________________________ Phone:_______________________________________

Parent Home Phone #:______________________________________ Cell #:_______________________________________

Allergies:_______________________________________________________________________________________________

________________________________________________________________________________________________________

NOTARY FORM

STATE OF _________________

COUNTY OF _______________

I, ____________________________________. a Notary Public, do hereby certify that on this

__day of ___________________, 20_, personally appeared before me ___________, known to

me to be the person whose name is subscribed to the foregoing instrument, and swore and

acknowledged to me that he executed the same for the purpose and in the capacity therein

expressed, and that the statements contained therein are true and correct.

_____________________________________________

Name, Typed or Printed:____________________________________

My Commission Expires:___________________________________

Immanuel Baptist Church Parental Permission Authorization Form