PERMISSION FORM
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ACTIVITY |
DATE(S) OF ACTIVITY |
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CHILD’S NAME |
SCHOOL GRADE |
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PARENT/GUARDIAN NAME |
HOME PHONE # |
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ALTERNATE EMERGENCY CONTACT & RELATIONSHIP |
PHONE # |
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The undersigned as parent or legal guardian of the minor child listed above, does hereby give permission for the above named individual to attend the above described activity of the Junior Youth Group at Our Savior Lutheran Church, 22-15 Broadway, Fair Lawn, New Jersey 07410. As a condition of attending, I do hereby release Our Savior Lutheran Church and all its affiliated organizations, as well as their officers, agents and employees, from any and all claims, demands, actions, or causes of action due to death, injury, or illness, in any way, arising from the above described activity, including, but not limited to transportation to and from the event. I further agree that the financial responsibility for securing care, in the case of injury resulting from participation in the activity, is a matter between the participant and his/her health care provider, and the Our Savior Lutheran Church cannot pay health care providers for treatment of any injuries. It is further agreed, that the participant will assume all legal responsibility for their personal safety and actions while participating in the activity and while traveling to and from the scheduled activity. Signature of parent/guardian________________________________ Date _____________ |
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AUTHORIZATION FOR MEDICAL TREATMENT I hereby authorize the treatment, administration of anesthesia, surgical treatment(s) for my minor child, listed above, in the event of a medical situation occurring in my absence, when the hospital or physicians are unable to contact me. This authorization extends to any hospital, physician(s), and nursing personnel within the physician’s staff where treatment is rendered in the physicians. I release from medical responsibility and liability the hospital, physician(s) and nursing personnel for performing medical procedures and acting on the authority of this medical treatment consent form, which such medical providers deem necessary for my minor child. Signature of parent/guardian________________________________ Date _____________ Please describe any medical conditions/issues (drug/food allergies, medications, conditions) for the above child:
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