Permission Slip

The Refuge 2011/12 Events

Permission Slip

Every activity sponsored by the youth group of First Baptist Church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By completing this form, you are giving permission for your student to participate in any or all Refuge activities throughout the 2011/12 school year. This also helps in decreasing the repetitive signing of permission slips for all youth events in this calendar year. Thank-you so much for your support!

General Information

Student’s Name: ______________________________________

Parent/Guardian’s Name(s): ____________________________________________

Home Phone Number: ____________________

Cell Phone Numbers: ______________________ _________________________

Health Insurance? Yes ______ No ______

Insurance Company: _____________________________

Insurance Policy Number: _____________________________

List any Medications (Name, dosage, time): _________________________________________

Any Allergies: _____________________________________________________

Medical/Liability Release

I, ______________________________, Parent or Guardian of ______________________________ give my permission for the First Baptist Church Youth Leaders to secure proper medical treatment for any and all youth events if necessary. I understand that every effort will be made to contact me first in the event medical attention is needed.

I also understand the general risks inherent in church-related youth activities and accept those risks for my student this year.

Signature ______________________________________ Date _________________

First Baptist Church • 247 E. Allegan St. • Otsego, MI 49078 • (269) 694-4160 • firstbaptist@fbcotsego.org