1110 S. Cornell Avenue Cherry Hill, NJ 08002 www.theconnectchurch.com _________________________________________________________________________________________________________________________
Permission Slip/ Medical Release Event: WAR 2013 Destination: Stevens, PA
Date of Event: March 15th thru March 17th 2013
Name of Attendee: _______________________________________________________________ Birth Date: ______-______-______ Address:________________________________________________________________ (City):______________________________________________ (Zip):______________ Parents Phone: (h)_________________________ (c)________________________ Your E-mail___________________________________ Parents E-mail_________________________________ School_______________________________________
Emergency Contact Information Contact #1 Name: __________________________________________________________________ Relationship _____________________________________________________________ Phone: _________________________________________________________________ Email: __________________________________________________________________ Contact #2 Name: __________________________________________________________________ Relationship _____________________________________________________________ Phone: _________________________________________________________________ Email: __________________________________________________________________
Please list any known medical allergies, medications being taken, medical problems, or other pertinent information needed in regard to participation of the above stated event: Please note that without this and the accompanying RELEASE AND COVENANT NOT TO SUE no one will be allowed to participate in the above stated event. I hereby affirm that I am the parent/legal guardian of said minor child and that I hereby give permission for him/her to attend the above described event. I (we) also understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give permission to the staff or sponsor to secure the services of a licensed physician and the providing of necessary medical services to provide the care necessary, including anesthesia, for the wellbeing of the above named minor child. I understand that the church will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/legal guardian.
Name of Parent/legal guardian :________________________________________________________ Date:_____________ Signature of Parent/ Legal Guardian:____________________________________________________ Date:_______________
_________________________________________________________________________________________________________________________ 1110 S Cornell Avenue Cherry Hill, NJ 08002 | 856 488 8820 p | 856 488 8870 f | www.theconnectchurch.com