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The Edge Permission and Medical Release Form The undersigned parent(s) or legal guardian(s) of: (Name of child)_______________________________ (Address) ______________________________________________________________give permission for this minor to attend Destiny Church Youth Events. I (we) release and hold harmless Destiny Church and its agents from any liability for any accident, injury, or loss of property of my (our) child. I (we) also give permission for above named minor to receive any emergency treatment (medical or surgical) and I (we) will assume responsibility for any such medical expenses incurred. I (we) also give permission for the above named minor to receive basic medication or first aid from the adults on the event. The adults may administer: _____ Aspirin _____ Tylenol _____ Ibuprofin. MEDICAL INFORMATION My (our) child has allergies to: (check and explain reaction) _____ medications _____ foods _______ insect bite/sting ___ other __________________________________________________________________ ___________________________________________________________________________________ My (our) child is taking the following medications: (list names and dosages) ______________________________________ ___________________________________________ ______________________________________ ___________________________________________ My (our) child has been vaccinated for tetanus (give date of last booster) _____________________________ Other medical conditions: (check where applicable) _____ rheumatic fever _____ asthma _____ diabetes _____ motion sickness _____ heart problems _____ seizure disorder _____ urinary tract difficulties _____ difficulty getting along with peers or authority figures (explain below)_____ other problems leading to unconsciousness (explain below) _____ any recent medical care received? (explain below):________________________________________ ___________________________________________________________________________________ Name and phone number of personal physician: ____________________________________________ Print Name of Father__________________________ Signed (father) ____________________________

Print Name of Mother_______________________ Signed (mother) ____________________________ Home Phone (parents) _____________________________ Cellphone (parents)____________________ Health Insurance Co./Policy Number:_____________________________________________________ Emergency Phone Number (friend, neighbor, relative): _______________________________________ Date signed ______________________________________ For some events, youth advisors may be needed to drive youth in private vehicles; I (we) also give permission for our son/daughter to ride in a vehicle driven by a youth advisor. Please initial ________


Permission slip  

for the dodgeball game

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