Greenbrier Church of Christ - Youth ministry

Permission/Release Form:     January 2005 - June 2005

  I/We give consent for (print name of your child/teenager):  

_______________________________________________________________

to attend Greenbrier Church of Christ Youth Ministry events/outings.  In the event that he or she is injured while under the care of Greenbrier church’s staff, paid or volunteer, and requires the attention of a doctor, I hereby consent to and will be responsible for any reasonable medical treatment as deemed necessary by a licensed physician.

I/We further agree to hold the licensed physician, the medical facility, the Greenbrier Church of Christ and its representatives free and harmless of any claims, demands or suits for damages arising from the authorization and provision of such medical treatment.  I/We understand the nature of the event and do hereby release the Greenbrier Church of Christ and its representatives from any liability due to accident or injury incurred by my child.  

I/We agree to cover all costs if our child needs to be sent home for disciplinary reasons.

  Parent/Guardian Signature(s) ________________________________________ Date __________________

*Please Print all information below*

Name of Parent or Guardian______________________________________________________________

Address_________________________________________________________________________________________

City________________________________   State__________   Zip_____________________

  Telephone at Home (               ) _____________ - _____________________

Telephone at Work    (               ) _____________ - _____________________

                                                                    Other phone (cellular/pager, etc.) (               ) _____________ - _____________________

Other Emergency Contact: __________________________________________  Relationship?_______________________________________

                                                                                                       Phone # (               ) ____________ - ________________________  

Special Medications or Medication Allergies ___________________________________________________________________________

Date of last Tetanus shot ________________________________________________________

Family Dr. _____________________________________ Dr’s Phone (              ) ___________ - ____________________

Insurance Company_______________________________________________________

Group # _________________________   Policy #________________________________________