July 12, 2006, Allegany State PArk Trip

PERMISSION/MEDICAL RELEASE FOR

Name ______________________________________   Phone ______________

Address _____________________________   City ______________________
Zip _______    Birth date ___/___/___  School  __________________________     

Parent/Guardian’s Name __________________________________________

Visitor?  Who invited you?  _______________________________________

I give permission for my child to join the Youth of Open ARms Community Church of Bradford, PA in any of the activities or trips sponsored by the church, its staff and sponsors.  I hereby release them from responsibility and liability for any illness or injury that my child may sustain during this activity.  In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state where services are rendered, either at a doctor’s office or in any hospital.  I expect to be contacted as soon as possible.

______________     _________________________________________
Date: Mo/Day/Yr       Parent’s Signature

Emergency Phone Numbers:  1. _____________   2.  _______________

Medical Information: (Required)

Allergies __________________________________________________

Medications being taken  ____________________________________

Physical handicaps  _________________________________________

Medical Insurance Co.  ______________________________________

Name of Policy Holder  ______________   Policy #  ______________