Medical Emergency and Parental Release Form Fr Soph Mission

					                      Medical Emergency and Parental Release Form
                               Fr/Soph Mission Trip 2010
                                   Denver, Colorado
                           Westlake Hills Presbyterian Church

Student’s Name ____________________________ Grade (fall -09)________

Student’s Email_____________________Parent E-mail________________________

Parents names__________________________________________________

Home Address________________________________________________

Home Phone _____________ cell phones:(father)___________ mother)__________

Date of Birth ____________

2 People to contact in case of emergency (other than parents):

Name & Phone number ___________________________________________

Name & Phone number____________________________________________

Pertinent medical information (i.e. allergies, medications, medical condition):

I, ________________ give my permission for my son/daughter _______________ to
participate in the Spring Break mission trip 2010, with the Student Ministries from WHPC. In
case of an accident or serious illness I hereby authorize Doug Congdon and the Student
Ministries Staff to seek whatever medical attention/treatment they deem necessary for the
welfare of my child. I understand that every effort will be made to contact me.

Parent Signature ___________________________________ Date _________
Please attach a copy of your student’s insurance card onto this form. Unless your student
attended Fun in the Son 2009 or Ski Trip 2008 or 2009, then we have it on file.

 Please return this form and $100 deposit to Cheryl Jones at WHPC, 7127 Bee Caves Road, 78746

Shared By: