Resurrection Youth Explosion!!! at 1211 S. Vineland Road, Winter Garden, FL 34787 US - Generic Permission Slip

Permission and Insurance Release for __________________________.

                                                                                    (Name)

Trip to:                                                                                                                

___________________________________ has my permission to participate in the

                       (Youth’s Name)

Resurrection Catholic Church __________________________________ starting _____________ at _______ at __________________________and completing at ______________________________ at _____________on ______________. 

Cost ____________________________________________________

________________________________________________________

I understand that neither Resurrection Catholic Church nor any of its agents are responsible for any injury sustained by my teen. I accept responsibility for any medical expenses as a result of any such injury sustained.

________________    ________________________________        ____________

(Phone number)           (Parent or Guardian Signature)                        (Date)

For Medical Release Purposes

To Whom It May Concern:

As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

This release is intended for (date) __________________________. This release form is completed and signed of own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signed _________________________________                   ________________

            (father, mother, legal guardian)                        (date)

__________________________________________________________________

Address                                            City                  State               Zip

            _____________________                  ______________________

            Home Phone                                        Work Phone

Family Physician: __________________________    Phone: ________________

Specific medical allergies, chronic illnesses or other condition: __________________________________________________________________

Another person to contact in case of emergency:

Name: ________________________________  Phone: ____________________