PARENTAL AUTHORIZATION FORM
CHRIST COMMUNITY CHURCH
YOUTH ACTIVITY

Please fill out this online Parental Authorization Form, sign it and make a copy of it to send with your Youth to Church.
The Youth Ministry will keep a hard copy on file while traveling with the Youth during the event.


PARENTAL AUTHORIZATION-CHRIST COMMUNITY CHURCH YOUTH ACTIVITY
Name of Student
Grade
Address
Parent(s) Name(s)
Home Phone
Work/Cell Phone #1
Work/Cell Phone #2
Family Doctor
Doctor's Office Number
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Home Number
Emergency Contact Work/Cell Number
Type of Event
Dates of the Event
Destination of the Event
MEDICAL INFORMATION - I hereby state that my son/daughter is in good health and can participate in all activities in this event - (Print Your Name in the Box to Confirm)
Medications and Instructions
Allergies
Any Other Special Circumstances or activities that they may not participate in
MEDICAL AUTHORIZATION - I hereby authorize any emergency treatment of my son/daughter that must be administered before I can be contacted. I wish to be advised as soon as possible of such treatment. I otherwise wish to be advised of any proposed medical treatment of my child prior to such treatment (Print Your Name in the Box to Confirm)
RELEASE - I agree on behalf of my son/daughter, to release, absolve, indemnify, hold harmless and defend Soular Youth Ministry and Christ Community Church, the chaperones, and the organizers of this event from any injury to, illness of, or cost of medical treatment for my son/daughter arising in connection with this event. (Print Your Name in the Box to Confirm)
INSURANCE RELEASE - I recognize that this event involves an element of risk incidental to such event and on behalf of myself and my son/daughter I hereby assume all such risk. I further recognize there is no medical insurance provided by Soular Youth Ministry of Christ Community Church. (Print Your Name in the Box to Confirm)
PERMISSION - I am granting permission for my son/daughter to participate in this SOULAR youth event. I understand that I need to print a copy of this completed form to be sent in with my son/daugther to church to confirm our permission. All online entries will be pending until a hardcopy of the Parental Authorization Form is turned in. (Print Your Name in the Box to Confirm)
Today's Date
Please print a copy of this form and add your signature in the designated box. Have your youth bring it in and deliver it to the Youth Pastor at Christ Community Church to reserve their spot on the trip. Thank You.