Portland Mount Hope Church

845 Ionia Rd   Portland, MI 48875   (517) 647-4136

                       Permission/Medical ReleaseForm

 

I ____________________, give my son/daughter________________ permission

to participate in Any Trips or Events in 2010 sponsored by Portland Mount Hope Church.  I give my permission to the AdultChaperone to drive my child on the trip.

 

In case of emergency, I can be reached at(phone): __________________________

 

If I can’t be reached in an emergency, please contact:

Name: ___________________________    

Phone: ___________________________

   

In the event of an emergency where I or the above mentioned can not be reached I givepermission to the adult chaperone to make the decisions for the Medical /Dental treatment of my teen or preteen. Thisauthorization extends to any emergency room treatment, and admission andtreatment as an inpatient, considered necessary by the attending physician

 

Medical Information:

My child’s doctoris:__________________________ Phone:__________________

Insurance Company:__________________________Policy #:________________

Is your child allergic to anything? if yeslist:_______________________________

_________________________________________________________________

Is your child on any medication? if yeslist:_______________________________

__________________________________________________________________

Can your child take Tylenol or other PainRelievers?            Yes                        No

 

Iunderstand that SWARM Student Ministry and its Student ministry staff are committed to providing safe, fun and educationalactivities, and that all SWARM Students activities are conducted in a smoke-,alcohol- and drug-free environment. In light of this, and to help ensure thesafety of all concerned, I understand that if my child is in possession ofdrugs, alcohol or tobacco products, engages in any illegal conduct, or refusesto follow the directions of SWARM Student  Ministry staff or volunteers while participating in thisactivity, I will be telephoned to immediately pick up my child.

I agree to not hold Portland Mount HopeChurch or any of its leaders responsible for any injury or loss of articleswhile involved in this program/activity.

 

Parents/Guardian Name(print):________________________________________ 

 

Address:___________________________________________________________

 

City:________________________________  State: MI  Zip Code:____________

 

Phone:     (          )              -                                  Cell    (          )             -                      

 

Parent/GuardianSignature:___________________________ Date:_____________