PARENT PERMISSION AND EMERGENCY FORM

I,_________________________________________ (parent or guardian name), release and discharge Trinity Southern Baptist Church, Fresno, CA and its staff and other chaperoning adults for all claims of damage, demands, actions whatsoever in any manner arising or growing out of my son/daughter's participation in the 2014 Focused Youth Spring Retreat April 4-6. I also agree to use our personal insurance as the main carrier in the event of accident or injury to myself, and/or my son/daughter. I also agree to assume responsibility for my son/daughter’s trip home in the event that it is deemed necessary for him/her to be sent home ( the use of drugs, cigarettes, alcohol, any restricted substance, or being an uncontrollable discipline problem are all acceptable reasons for such action). In the event that I cannot come and get my son/daughter, I assume the financial obligations for getting him/her home. I also give my consent for any necessary medical attention in case of an emergency.

I have read and understand the statement above:_____________________________________

Parent/Guardian's Signature

Son/Daughter’s Emergency Information:

Son/Daughter’s Name____________________________________

Address _________________________________________________

City_____________________________ Zip_____________________

Home Phone____________________________________________

Parent’s Work #’s (mom)_____________________ (dad) __________________

Parent’s Cell #’s (mom)__________________ (dad) __________________

Doctor's Name____________________________________________

Address____________________________ Phone__________________________

Insurance Name___________________________________________

Insurance Number_________________________________________

My son/daughter is allergic to:

______________________________________________________________________________________

(If more room is needed please use back of this form)

Friend or relative to be called in case of emergency if parents cannot be reached.

Name:___________________________________________Phone #_____________________