Church Youth Permission Slip

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__________ Church Youth Permission Slip
YOUR PARENTS FILL IN THIS PART:
I give permission for my son/daughter _________________ to participate in ____________ with
__________________ Church and/or the Episcopal Diocese of Maine. I give permission for his/her
photograph taken at the event to be used for publicity purposes. I absolve the church, the Diocese of
Maine, the sites and their employees and volunteers from responsibility for accident or injury which
may occur during any aspect of this event, including transportation to, from and during the event. I
give permission to the adult(s) in charge to give medications to him/her and to provide or get
emergency medical treatment for him/her, and I will be financially responsible for any such treatment.
Insurance Company & Policy Number: _______________________________________________
Important medical information: ____________________________________________________
: ______________________________________________
Prescription Meds s/he is allowed to bring
Print parents’ names: ____________________________________________________________
Emergency phone numbers of parents: ______________________________________________
Parent's signature: ____________________________________
Date: _________
**************************************************************
YOU FILL IN THIS PART:
Name: _____________________________________________________ Gender: ______ Grade: _____
First name for nametag: _______________________________ Birthday: ________________ Age: ____
Address: _____________________________________________________________________________
Home Phone (land line): _____________________ Cell phone, if you have one: ____________________
Which phone is the best way to reach you? ______________________
E-mail: ________________________________________________ Are you a vegetarian? ____________
Your church and its town: ___________________________________ School: _____________________
Can we send you important information by e-mail?
____ Yes
____ No
Today’s date: _______________________________

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