Permission_Slip by ashrafp

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									                       Apple Valley Church of the Nazarene
               P.O. Box 2636 Apple Valley, CA 92307 (760) 247-8433

       PERMISSION SLIP, MEDICAL AND LIABILITY RELEASE FORM

Name__________________________________________Birthday_____________

Address__________________________________________Phone_____________

City_________________________________State___________Zip____________

In emergency, notify________________________________Phone_____________

Doctor_________________________City_______________Phone_____________

***I, the parent/guardian of _______________________give my permission for him/her to
participate in the organized activities of the Apple Valley Church of the Nazarene NYI. I
understand that these activities will be under the supervision of the youth pastor and
volunteer sponsors. If for any reason my son/daughter gives cause to be dismissed from an
activity, I agree to provide or pay for necessary transportation to pick up my child. This
permission is granted for the dates of January 1, 2009 through December 31, 2009.

Signature________________________________________Date________________

                     HEALTH & INSURANCE INFORMATION

Date of last tetanus shot___________Any known allergies____________________

Current Medications___________________________________________________

Do you have health insurance?_______Yes _______No

If yes, name___________________________________Policy #________________
***I, the parent/guardian of____________________do hereby authorize (those working in
accordance with) the Apple Valley Church of the Nazarene to consent to any medical or
surgical treatment and hospital care which is deemed advisable by any licensed physician or
surgeon. I understand that I will be contacted as soon as possible in the event of any
emergency.

Signature________________________________________Date________________

                                 LIABILITY RELEASE
Every activity sponsored by this church is carefully planned and adequately supervised.
However, even with the best precautions, unforeseen accidents may occur. Upon signing this
form, I, the parent/guardian of ______________________, agree to assume and accept all
risks and hazards inherent in church-related activities. I also agree not to hold the church of
it’s employees or sponsors liable for dangers, losses, or injuries to the above named
son/daughter.

Signature________________________________________Date________________

								
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