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THE UNITED PRESBYTERIAN CHURCH 2550 ROCK HILL ROAD WOOD RIVER, ILLINOIS 62095 PHONE: 618-254-5880 Van Ministry Permission Slip/Medical Release
Participant’s Name(s) ___________________________________________________________________ Address ______________________________________________________________________________ City, State and Zip _____________________________________________________________________ Phone ______________________________ Grade(s)/Age(s) __________________________________ I give permission for my child(ren) to ride in The United Presbyterian Church van to and from Youth Quest on Sunday evenings throughout the program year (September-May). I understand this service has been approved by the Session and the Pastor of the church and that only insurance-approved adult sponsors 25 years and older, who are licensed and insured, 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 service. In the event of an emergency, I expect to be contacted as soon as possible. Parent/Guardian Signature __________________________________________________________ Please print above name __________________________________________________________ Emergency Phone Number ______________________________ Date ______________________ [Please cut on the above line.] [Give the top portion to the van driver, and retain the bottom portion for your records.] The United Presbyterian Church 618-254-5880 Call this number to leave a message on the voice mail at the church by 4 p.m. on Sunday afternoon if your child does *not* require pick-up. Otherwise, he/she will be figured into the route. Leave your name, address, and phone number, so the driver may contact you if there is a question. Feel free to call this number after 5:30 p.m. to check on your child’s safe arrival and/or departure schedule. Thank you for sharing your child(ren) with us! Julie Gvillo, Youth and Families Pastor Rev. Pam Laing, Pastor Michael Carnes, Van Ministry Coordinator The United Presbyterian Church
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