MIME-Version: 1.0 Content-Location: file:///C:/A21B3D90/Youth_Permission_Slip.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" CONSENT AND RELEASE FROM LIABILITY FROM

CONSENT AND RELEASE FROM LIABILITY FROM

BURLEY BIBLE CHURCH, PORT ORCHARD, WA

 

To be completed by the event leader.

The Function/Activity Is:  _________________________________________________

The Location of This Is:    _________________________________________________

Date or Dates of Activity:  _________________________________________________

Departure Time:         =        ____= ____________         Return Time:  _________________

 

I, ____________________________ , the ___________________________________ of

        =             &nb= sp;      (father, mother, guardian)

______________________________ , do hereby consent to his/her participation in the

(print child/youthR= 17;s name)

function or activity of the youth/children’s min= istry of Burley Bible Church as described above.

 

Doctor’s Name/Phone:<= span style=3D'mso-spacerun:yes'>      _________________________________________________

Health Insurance Carrier:  _________________________________________________

Policy Number:  _________________________________________________________

 

My child, _____________________ , is affected by the following medical conditions and is currently taking the following medicati= ons prescribed by our doctor:

Medical Condition:  _____________________________________

Medication:             _____________________________________

 

I authorize the leaders of the function/activity to ob= tain any emergency medical care and treatment deemed necessary.

 

I DO HEREBY RELEASE AND HOLD HARMLESS BURLEY BIBLE CHU= RCH, and all of its ministries and departments, each of the leaders and each of = the accompanying persons FROM ALL LIABILITY for mishap or injury of any nature whatsoever.

 

I understand that all of the participants attending th= is function/activity will be advised of, and required to abide by, the proper = code of conduct and the rules of this function/activity.

 

DATED this ______________________ day of _____________________ 20 _________

 

______________________________                 _________________________________

SIGNATURE Parent or Guardian           &nb= sp;           Home Phone #

 

______________________________                 _________________________________

Emergency Name & P= hone #        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                 Second Emergency Name & Phone #