HARVEST FELLOWSHIP PERMISSION SLIP
Event: _______________________________________ Date and Times: ___________________________
Date of Birth: ______________________ Current Grade: ___________
I hereby grant permission for my child to participate in the above activity of Harvest Fellowship Youth Group. I understand that my child participates in these activities at his/her own risk and that Harvest Fellowship, its staff, and adult supervisors, individually and severally, 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 that return or come pick up my child.
I recognize that Harvest Fellowship uses photographs and video images from events in publicity materials such as the church website, Facebook page, etc., and I hereby grant permission for photo/video images of my child to be taken and used for such purposes.
In the event of a medical emergency, I authorize the treatment of the child named above by a qualified and licensed medical practitioner if, in the opinion of the medical professionals present, such treatment is emergently necessary. This authority is granted only after reasonable effort has been made to secure my personal consent. I acknowledge that I am responsible for all medical expenses incurred.
Print Parent/Guardian Name: __________________________________
Signature: __________________________________ Date: __________
Phone: (H) _____________ (W) ______________ (C) _____________
EMERGENCY CONTACT NAME AND PHONE NO.: ____________________________________________
ALLERGIES – if none, please write, “none” ______________________________________________________
ACTIVITY RESTRICTIONS – if none, please write, “none” _______________________________________
CURRENT MEDICATIONS – if none, please write, “none” _________________________________________
OTHER INFORMATION (special needs or concerns) – if none, please write, “none” _____________________
Medical Insurance Co.: ____________________________Policy/Group/ID No.: ________________________
Phone No.: _________________________________________________
Primary Care Physician Name and Phone No.: ____________________________________________________