The House Permission Form
Student's Name:
Student's Birthdate:
Parent/Guardian Name(s):
Address, City, Zip:
Home Phone:
In an emergency if I cannot be reached, contact:
Emergency Contact's Phone Number:
Physician's Name:
Physician's Phone Number:
List any allergies or medications:
Insurance Co. Name:
Policy No.:
Insurance Phone:
I give permission for my child to go to: (PLACE)
With The House middle school ministry of Moraine Valley Church on: (DATE)
In
the event that I cannot be reached in an emergency, I hereby give
permission for the leadership of The House middle school ministry at
Moraine Valley Church to have an authorized doctor or medical
professional administer medical aid and treatments for my teen at any
time they believe an emergency exists. I will be responsible for all
medical bills. I agree not to hold the church or the leaders
responsible for any accident should it occur.
Parent/Guardian Signature:
Date:
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