Middle School and High School

Permission Form

EVENT:

DATE:

Dear St. Lucas United Church of Christ Parent,

This form must be completed in full before your son/daughter will be permitted to participate in this event.

Both sides of this permission form must be completed.

PLEASE COMPLETE AND RETURN ON OR BEFORE .

YOUR SON/DAUGHTER CANNOT ATTENT THE EVENT WITHOUT THIS FORM.

(Name of Youth) HAS PERMISSION TO ATTEND THE ABOVE EVENT/DATE.

I am fully aware that I will take full responsibility for my child's conduct. I release the chaperons from liability for any injury that may be sustained by my son/daughter due to circumstances over which said chaperons cannot reasonably be expected to have any control. I do release St. Lucas United Church of Christ from total liability. I will instruct my son/daughter on the necessary rules of safety and good Christian conduct.

This form is valid only when the attached Chaperone's Statement of Responsibility is also signed.

_______________________________________________

Signature of Parent/Guardian

_______________________________________________

Address of Parent/Guardian

_______________________________________________

Telephone Number (during event)

Date of EVENT: __________________________________

CHAPERONE'S STATEMENT OF RESPONSIBILITY

By accepting the role of chaperone(s), I accept the responsibility to exercise the standard of care (for the youth named on the PARENTS PERMISSION part of this form) a prudent adult under the same circumstances would exercise that.

_____________________________________________

Signature of Chaperon(s)

______________________________________________

Date signed

_____________________________________________________________________

EMERGENCY TREATMENT RELEASE

For this event only!

To whom it may concern:

As a parent/guardian, I do herewith authorize the treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency, which in the opinion of the attending physician may endanger his/her life cause disfigurement physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor: _____________________________Birthdate:__________________________

Relationship to you: _____________________________________

Date or Dates when release is intended: _________________________________

This release form is completed and signed of my on free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signed: Date: _____________

TO REACH PARENT/GUARDIAN IN CASE OF EMERGENCY:

Telephone (home): ____________________ (work): _________________________________

Cell Phone: __________________________Pager: _________________________________

Address: _______________________________________________________________________

_______________________________________________________________________________

PERSON RESPONSIBLE FOR YOUTH IN MY ABSENCE.

NAME: Gina Pona-Norton or Kit Norton, St. Lucas Coordinators of Youth Ministry

FAMILY PHYSICIAN INFORMATION

Physician Name: __________________________________

Telephone: _________________________

Last Tetanus Booster Injection:

Allergies:

Present Medication:

Chronic Illness (i.e. asthma, diabetes, epilepsy, etc.):