OCYG

Permission/Liability Release Form

Name:___________________________________________

Phone:________________________

Address: ________________________________________________

City/Zip:________________________________________

I give my permission for my above-named child to join the teenagers of the Otter Creek

Church of Christ for________________________________(Name of Event) from ___________

until _______________(Starting and Ending Dates). I understand that the group will be

traveling either by church van, rental vehicle or personal vehicles driven by licensed adult

chaperones.

I hereby release Otter Creek Church of Christ and the staff, both paid and volunteer, from responsibility and liability for any injury that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of the activity, as an agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state in which services are rendered, either at a doctor’s office or hospital. I expect to be contacted as soon as possible.

Signature of Parent or Legal Guardian:______________________________________________

Date: ________________________

Emergency Contact Name and Number:______________________________________________

Medical Information

Allergies:_____________________________________________________________________

Medications Being Taken:________________________________________________________

Physical Handicaps pr Limitations:_________________________________________________

Medical Insurance Company:______________________________________________________

Policy #:______________________________________________

Group #:______________________________________________

Members Name:_______________________________________