Church Registration Template by cyg16960

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									       MISSION TRIP/RETREAT/CAMP PERMISSION & MEDICAL RELEASE
NAME: __________________________________________________________________________

STREET ADDRESS: ________________________________________________________________

CITY: ____________________________ STATE: _______________ ZIP:__________________

PHONE (HOME): _______________________________ (CELL): __________________________

EMAIL: _________________________________________________________________________

CHURCH AFFILATION (IF OTHER THAN FBC/LSL): _____________________________________

AGE AT TIME OF TRIP: __________________________ BIRTHDATE_______________________

EMERGENCY CONTACT NAME: ________________________________________________________

EMERGENCY CONTACT PHONE: _______________________________________________________

MEDICATIONS: ___________________________________________________________________

ALLERGIES:______________________________________________________________________

SPECIAL CONDITIONS: ____________________________________________________________

The person described on this registration form has my permission to be in all
activities at the designated places during the dates associated with the trip,
except as noted by me and listed on the bottom of this sheet. If a medical
emergency should arise while my child is on this trip and I cannot be reached, I
consent and give permission to the trip director or representative youth leader
to select a physician and/or hospital for care.

I also give the physician and/or hospital, as selected by the trip director or
representative youth leader, my permission to hospitalize, treat, give x-rays,
test, order injections, anesthesia, or provide surgery for my child who is named
herein. I do release, acquit, discharge, and covenant to hold harmless 1st
Baptist Church of Lake St. Louis, the trip director, other youth leaders, or any
other associated churches of any and all actions, damages, or liabilities
arising out of the treatment of any sickness, or accident incurred by my said
child. If the person herein named above is of the legal adult age of 18, they
are legally able to sign for themselves if it is so desired.

SIGNATURE OF PARENT/GUARDIAN: __________________________________________________

AND/OR
SIGNATURE OF PERSON ATTENDING IF LEGAL AGE 18):_________________________________

PERMISSION SLIP
I, ______________________________________________________________ am the legal

guardian of ________________________________________________________ and give my

permission to attend this extracurricular church function.

SIGNATURE:

								
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