NAME OF MINOR___________________________________ AGE________ BIRTH DATE_______________

                                                                                                                                    Month/day/year

ADDRESS ________________________________________ SOCIAL SECURITY NO. ______-______-______

_________________________________________________ PHONE (_______)-___________-__________

CHURCH SPONSORED ACTIVITY_____________________________________________________________

IN AN EMERGENCY, IF I CANNOT BE REACHED, PLEASE NOTIFY THE FOLLOWING PERSON

NAME ____________________________________________ PHONE (_______)-___________-__________

   In the event that the above named minor becomes ill or sustains injury while on an authorized and chaperoned outing sponsored by the Presbyterian Church of Havre de Grace, Maryland, I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and to administer first aid. In the event that immediate treatment is reasonably necessary or I cannot be reached within an appropriate time, I also consent to any X-Ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the above named minor under the general or special supervision and on the advice of any duly licensed physician, surgeon, and/or dentist, whether such diagnosis or treatment is rendered at the office of said physician, surgeon dentist, or a licensed hospital.

   The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned minor pursuant to this authorization.

   Should it be necessary for the aforementioned minor to return home due to medical reasons, behavioral problems, or otherwise, the undersigned shall assume all transportation costs.

   I hereby give permission for the above named minor to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in the activities sponsored by the Presbyterian Church of Havre de Grace.

INSURANCE COMPANY _______________________________________

POLICY NO. ________________________________________________

PHONE ____________________________________________________

PLEASE INDICATE THE DATE MINOR LAST RECEIVED HIS/HER TETANUS IMMUNIZATION

             MONTH_____________________ YEAR__________________

LIST ANY ALLERGIES MINOR MAY HAVE (include allergies to medication and anesthesia).

 LIST ANY SPECIAL HEALTH OR MEDICAL PROBLEMS (Please describe) _____________________________

LIST ANY MEDICATIONS WHICH MINOR IS CURRENTLY TAKING

1.
2.
3.
4.
5.
6.

I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge all sponsors and the Presbyterian Church of Havre de Grace, Maryland, from any and all claims, demands, actions, or cause of action, past, present, or future arising out of any damage or injury while participating in the above named activity. I also do hereby authorize the use of a photocopy of this instrument in lieu of the original which is on file in the church office.

Dated this __________day of _______________, 20________

Signature________________________________ Relationship____________________________

THIS FORM IS VALID FOR THREE YEARS. IF ANY CHANGES OCCUR IN YOUR CHILD’S CONDITION,

YOU MUST NOTIFY THE PRESBYTERIAN CHURCH OF HAVRE DE GRACE AND COMPLETE A REVISED FORM.

TO BE COMPLETED BY NOTARY

On this the _______day of ____________, 20____, personally appeared before me___________________,

Personally known by me, and in my presence executed the within and foregoing permission and release form. Witness my hand and official seal.

                                                                           _________________________________ Notary Public

My commission expires __________________________