Name:

Address:

City:                             State:                  

Zip:

Phone: 

Person to Notify:

Emergency Phone Numbers:

Insurance Company:

Policy Number:

Policy Holder:

In the event of an emergency, where medical treatment is required, I give my permission to the church staff or sponsors to obtain the services fo a licensed physician. 

Signature: 

Date: 

If your child will be taking any medications please explain on back and give all medications to sponsor on day of trip.  Also list on back the event name and dates.  Thank you!