PARENTAL PERMISSION AND MEDICAL AUTHORIZATION

Parents and legal guardians of minor children must complete this form for every child who participates in youth group activities and return it to Holy Cross Lutheran Church.  The information is designed to assist the church in providing for the safety of minors during church sponsored activities.

General Information:

Child’s Name_____________________________________Date of Birth_________________________

Parent’s Name____________________________________Home  Phone_________________________

Cell Phone _________________________________ Work Phone_______________________________

Address_____________________________________________________________________________

Parent’s Name____________________________________Home  Phone_________________________

Address_____________________________________________________________________________

Cell Phone _________________________________ Work Phone_______________________________

Person to call in emergency (other than parent)______________________________________________

Relationship____________________________________________Phone_________________________

Parental Consent:

I, the undersigned, being parent or legal guardian of the child named above do hereby consent to the participation of my child in the activities which may include, but are not limited to, lock ins, retreats, ropes courses, bowling, swimming, hiking, camping, trips out of Athens/Oconee area, and other activities that may be associated with youth groups of Holy Cross Lutheran Church of Athens, GA.

I do NOT authorize my child to participate in the following activities: ____________________________

_____________________________________________________________________________________

Medical:

Health Insurance Company______________________________________________________________

Policy Number________________________________________________________________________

Doctor’s Name and phone_______________________________________________________________

Is your child currently being treated for any medical condition? If yes, please explain _______________

 ____________________________________________________________________________________

Is your child currently taking any medication?  If so, please list medication and doses________________

_____________________________________________________________________________________

(Note:  If temporary medication becomes necessary throughout the year, please be sure to advise youth leaders of the type and dose.)

Is your child allergic to any medication or food? If yes, please explain  ____________________________

___________________________________________________________________________________

Does your child require any special diet? (If yes, please explain)   ________________________________

____________________________________________________________________________________

Does your child swim?  yes_____  no_____   Does your child ever sleepwalk?  yes______  no______

Does your child have any physical handicap or illness which would prevent him/her from participating in normal vigorous activity? 
(If yes, please explain) ___________________________________________

____________________________________________________________________________________

Is there anything else concerning your child that we should know about? __________________________

____________________________________________________________________________________

Web Site Consent:

Yes ___________ (initial please)  No ___________

Medical Treatment Authorization:

            “I understand that I will be notified in case of a medical emergency involving my child.  However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill.  I understand that the church will not be responsible for medical expenses incurred, but
that such expenses will be my responsibility as parent/guardian.
     I agree to notify the church in the event of any health changes that would restrict my child’s participation in normal youth group activities.  I also understand that the adult supervisors reserve the right to restrict my child from any activities that they do not feel is within the physical capabilities of my child."