Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone _ _ _ _ _ _ _ _ _ _ _ _

City _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ Zip Code _ _ _ _ _ _ _ _ _

Parent(s) Work and/or Cell # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I, the undersigned, give permission for my/our child, _ _ _ _ _ _ _ _ _ _ _ to attend any and all events/activities sponsored by House of Prayer Lutheran Church Youth Group.

I/we authorize an adult, in whose care the minor has been entrusted, to consent to any medical or dental diagnosis or treatment as required in a medical emergency in which case I cannot be immediately contacted for such consent.

The undersigned shall be liable and agrees to pay all cost and expenses incurred in connection with such medical and dental services rendered to the above mentioned child. If it becomes necessary for my/our child to return home due to medical reasons or otherwise, the undersigned will assume transportation costs.

The undersigned gives permission for my/our child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while participating in events/activities sponsored by House of Prayer Lutheran Church.

Insurance Company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Name on Policy _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Policy # _ _ _ _ _ _ _ _ _ _ _

Primary Care Physician _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone # _ _ _ _ _ _ _ _ _ _ _

Emergency Contact _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone # _ _ _ _ _ _ _ _ _ _ _
(Other than Guardian)

Allergies, medical conditions, or medications of participant : _ _ _ _ _ _ _ _ _ _ _

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Parent(s) or Guardian(s) Signature(s): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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