My son/daughter __________________________________ (full name) has my permission to participate in any events sponsored by Tanner Trails Community Church from September 1, 2008 through August 31, 2009.
Signature: _____________________________________________ Date: __________________________
In the event that our child ___________________becomes ill or sustains an injury while on an authorized and chaperoned outing from Tanner Trails Community Church, I the undersigned, give my permission to those in charge to take whatever steps necessary to stop any bleeding and to administer first aid.
I also consent to an X-ray examination, anesthetic, medical (or dental) or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon.
I release Tanner Trails Community Church and its agents from all liability in connection with the foregoing actions.
I understand that this consent will apply to all emergency situations present and future, and that a copy of this form is as valid as the original. This consent is to remain in effect until written revocation is made.
Date: _______________________________ Signature: ________________________________________
(Parent or legal guardian)
Name of both parents/guardians: __________________________________________________________
Address: ______________________________________________ Phone: ________________________
(Home)
Phone: ________________________
(Work)
List Any Special Health Problems: ________________________________________________________
_____________________________________________________________________________________
Medications (Name/dose/prescribing physician) _____________________________________________
_____________________________________________________________________________________
Regular physician: ________________________________ Phone: ______________________________
Birthday of child: ______________________________________________________________________
In the event we cannot be reached during an emergency, please contact:
Name: _________________________________________ Phone: _______________________________
Insurance Company/Policy Number: _______________________________________________________
Please Return This Form to TTCC