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OPPORTUNITIES FOR YOUTH Christ Episcopal Church Youth Group 120 S. New Hampshire Covington, LA 70433 985-892-3177 Fax 985-892-3187 www.christchurchcovington.com Permission Form Destination ___________________________________________________________________ Date _____________________________Time Leave ___________Time Return_____________ Additional Info ________________________________________________________________ ------------------------------CUT---------------------------------------CUT--------------------------------------------------- CONSENT TO EMERGENCY MEDICAL TREATMENT AND RELEASE My child, ___________________________________, has my permission to attend the trip/event described below under the direction of an adult sponsor. I understand that, in the event that my child requires medical attention while attending the trip/event described below, an adult sponsor will make every reasonable attempt to contact me. In the event that my child requires medical attention while attending the trip/event and my consent is unavailable, unobtainable, or impractical to obtain, or when in the sole discretion of the adult sponsor, the circumstances require immediate emergency medical decisions or attention, I hereby grant to the adult sponsors unlimited permission to make medical decisions, including administering medication and authorizing surgery for my child. I hereby agree on my own behalf and on behalf of my child to RELEASE, DISCHARGE AND HOLD HARMLESS the adult sponsors of the trip/event described below and Christ Episcopal Church in Covington, Louisiana, its employees, agents, representatives, and volunteers from any and all suits, claims, demands, actions, liabilities and damages of every kind and character arising out of or in connection with my child's attendance and participation in the trip/event described below, including but not limited to claims for personal injury, sickness or with respect to medical decisions made by adult sponsors pursuant to the permission granted above. ______________________________________________________________________________ Destination and Date ______________________________________________________ Parent’s signature Date ____________________________________________ Parent’s phone (home) Parent (cell) Can Parent participate in driving? __________________________________________________ If so, how many can Parent transport? _______________________________________________ All drivers must have proof of insurance and driver’s license. Click here to download the printable version of the CCY Permission Form |
