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Guntersville Youth Ministry Permission Slip and Medical Release

I do hereby give my permission for my son/daughter to go on any Youth Trip from January 1 of 2020 through December 31 of 2020. I release Guntersville Church of Christ, and the sponsors of this event from liability for any accident that may occur during the event, or while traveling to, from, and during youth trips. It is my understanding that these trips and activities are approved by the church and will be appropriately chaperoned by adult leaders and parents.

Additionally, in the event that my teen becomes ill or sustains an injury during one of these trips, I give my permission to those in charge to take the necessary steps in administering proper medical treatment. In the event that I cannot be reached by phone, I consent to the administration of treatment to be rendered to my teen upon the advice of a duly-licensed physician and/or surgeon.

I understand that I am giving permission for my teen to engage in these trips and all activities, and I will not hold the staff, Guntersville Church of Christ, or sponsors responsible for any incident occurring to my teen resulting from reasonable activities during these events.

First Youth's Name

First Name*

Middle Name

Last Name*

Phone*
First Youth's Date of Birth*
First Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
First Youth's Signature*
Second Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Second Youth's Date of Birth*
Second Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Third Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Third Youth's Date of Birth*
Third Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Fourth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Youth's Date of Birth*
Fourth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Fifth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Youth's Date of Birth*
Fifth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Sixth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Youth's Date of Birth*
Sixth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Seventh Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Youth's Date of Birth*
Seventh Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Eighth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Youth's Date of Birth*
Eighth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Ninth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Youth's Date of Birth*
Ninth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Tenth Youth's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Youth's Date of Birth*
Tenth Youth's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Youth's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Alternate Number for parent/guardian

Name of an alternate emergency contact besides a parent

Phone number of alternate emergency contact
Alternate Emergency Contact (other than parent/guardian)

Alternate Emergency Contage
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 19 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Does the youth have any known allergies? If so, please list below along with any other pertinent information

Does the youth take any prescription medicine? If so, please list all prescription medications and dosages.

Date of Last Tetanus Shot *

Any other information you would like for us to know:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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