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THE
UNITED PRESBYTERIAN CHURCH Participant’s Name______________________________________________________________ Address_______________________________________________________________________ Phone________________________
Grade/Age____________ I give permission for my child to participate in the church sponsored Youth Quest trip to Belk Park in Wood River, IL on May 2, 2010, and for her/him to participate in all of the associated activities. I understand the activity has been approved by the Session and the Pastor of the church and that my child(ren) will travel together and that only adult sponsors 25 years and older will drive. I hereby release The United Presbyterian Church, its staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during activities that are a part of this trip. In the event of an emergency, I hereby authorize an adult leader of the activity, as agent for me, to consent to any X-ray examination, medical, dental, or surgical treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate). I expect to be contacted as soon as possible.
Parent/Guardian Signature_________________________________________________________________ Please print above name__________________________________________________________ Emergency phone____________________________________________________________________ Allergies______________________________________________________________________ Medication(s) being taken________________________________________________________ Physical handicaps or limitations__________________________________________________ Medical Insurance Company_____________________________________________________ Policy number _____________________Member’s Name______________________________ Date____________________________
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