Youth Permission Form

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Participant's Name (First & Last):

Participant's Date of Birth:

Participant's Address and Phone Number:

Grade:

Mother's Name (or Guardian):

Mother's Address (if different from participant):

Mother's Daytime Phone Number:

Mother's Evening Phone Number:

Mother's Pager or Cell Phone Number:

Father's Name (or Guardian):

Father's Address (if different from participant):

Father's Daytime Phone Number:

Father's Evening Phone Number:

Father's Pager or Cell Phone Number:

Primary Physician's Name:

Physician's Phone Number:

Please indicate allergies/special medical concerns of which the leaders should be aware:

First Emergency Contact Person's Name, Home and Cell Phone #s:

First Emergency Contact Person's Relationship to the Participant:

First Emergency Contact Person's Address:

Second Emergency Contact Person's Name, Home and Cell Phone #s:

Second Emergency Contact Person's Relationship to the Participant:

Second Emergency Contact Person's Address:

Insurance Company Name and Address

Insurance Company Phone Number

Policy Holder's name, address & phone number

Policy Holder's Relationship to Youth

Policy Number

Group Number

Date and Location of Outing

In the event of an emergency/non-emergency situation in which medical treatment is required every reasonable effort will be made to contact the persons listed. If this fails:

Consent is hereby given to the Pastors, and/or authorized Lay Leadership of Kingswood UMC to authorize proper treatment.

Treatment under recommendation of qualified medical personnel may include transportation, hospitalization, injection, anesthesia, or surgery.

Parent's Signature and Date

Please Print Form and Hand In