Annual Youth Permission Slip Form

 

HIGH SCHOOL/MIDDLE SCHOOL YOUTH PERMISSION SLIP
Date (required)

NOTE: This form must be completed annually for St. Mark's Youth Group.

In the event of a medical emergency, I/we declare that I/we are the child’s parent or legal guardian and hereby authorize the St. Mark’s Youth Ministry Staff, as agents for me/us, to consent to x-ray exams or other medical, dental or surgical diagnosis and treatment that is advised and supervised by a physician, surgeon or dentist. This authorization extends to any emergency room treatment, and admission and treatment as an inpatient, considered necessary by the attending physician. I understand that, in the event of such an emergency, I will be contacted as soon as possible.

• I/we assume all financial responsibility for the medical bills.
• I/we understand that St. Mark’s United Methodist Church and/or its adult sponsors are not responsible for any injuries or accidents sustained on this trip.

STUDENT INFORMATION

Student's Name (required)
Address
City
State
Zip
Date of Birth (required)
Gender:
MaleFemale
Student's Email
Mobile Phone

PARENT INFORMATION

Parent(s) Name (required)
Parent Mobile Phone (required)
Parent Other Phone
Parent Email Address
Alternate Contact Person
Alternate's Phone

MEDICAL INFORMATION

Family Physician
Physician Phone
Medical Insurance Company
Insurance Contract/ID Number

Insurance Phone
Student Allergies (meds, foods, etc.)

Current Medical Problems
Month/Year of Last Tetanus (Tetanus Toxoid; DT; or DPT)
Does Student take Medication(s) regularly?NoYes
Detail medications and instructions
Will student have medications with him/her? NoYes

MEDICATION MUST BE IN ORIGINAL CONTAINER
I also give permission for my child to receive Tylenol/Advil upon request for minor pain at the discretion of the youth staff. I understand that pictures may be taken of my child while he/she is at the event and may be used for publicity purposes by St. Mark’s United Methodist Church.

AUTHORIZATION AND SIGNATURE

I warrant the truthfulness of the information provided in this permission slip.
Electronic Signature (please type your First and Last Name)

I understand that checking this box constitutes a legal signature confirming that I acknowledge and grant the above permissions.