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Linary Children Ministry Permission Slip and Medical Release


I do hereby give my permission for my son/daughter to go on any event from January 1 of 2022 through December 31 of 2022. I release Linary 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 these events. It is my understanding that these events and activities are approved by the church and will be appropriately chaperoned by adult leaders and parents.

Additionally, in the event that my child becomes ill or sustains an injury during one of these events, 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 child upon the advice of a duly-licensed physician and/or surgeon.

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



First  Name

First Name*

Last Name*

Phone*
First  Age Acknowledgment*
First  Date of Birth*
I certify that I am 18 years of age or older
First  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  Signature*
Second Name

First Name*

Last Name*
Second Date of Birth*
Second 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 Name

First Name*

Last Name*
Third Date of Birth*
Third 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 Name

First Name*

Last Name*
Fourth Date of Birth*
Fourth 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 Name

First Name*

Last Name*
Fifth Date of Birth*
Fifth 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 Name

First Name*

Last Name*
Sixth Date of Birth*
Sixth 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 Name

First Name*

Last Name*
Seventh Date of Birth*
Seventh 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 Name

First Name*

Last Name*
Eighth Date of Birth*
Eighth 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 Name

First Name*

Last Name*
Ninth Date of Birth*
Ninth 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 Name

First Name*

Last Name*
Tenth Date of Birth*
Tenth 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:
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

First Name*

Last Name*

Emergency Contact's Phone Number*
Alternate Emergency Contact

Name of Alternate Emergency Contact

Phone Number of Alternate Emergency Contact
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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