PARENTAL CONSENT & MEDICAL INFORMATION

FOR ATTENDANCE OF YOUTH ACTIVITIES AT

EASTERN AVENUE CHRISTIAN REFORMED CHURCH

* Answer required (if not applicable type in NONE)

PERSONAL INFORMATION

* Child/Youth Name

* Date of Birth

* Parent/Guardian

* Email Address

* Home Phone

* Work Phone

* Cell Phone

* Address

* City

* ZIP

* Medical Insurance Company

* Policy Number

PERTINENT MEDICAL INFORMATION

* Physician

Clinic/Practice

* Current Medications (name, dosage, time, other instructions)

* Allergies (food, medicine, insects, other - please be specific)

This form is a permission slip for youth events, programs, and activities that your child may participate in while attending Eastern Ave. CRC. These programs include: Church School, Children & Worship, Little Stars, Shining Stars, GEMS, Cadets, WEB Tutoring Program, Middle School Youth Group, High School Youth Group.

* I (name)

* give permission for my child (name)

to participate in youth programs and events sponsored by Eastern Avenue CRC. I know that occasionally there may be field trips or special outings that may include being transported by a youth leader. I also know that at times photos may be taken or videos taped for publications used by Eastern Ave. CRC. I also give permission to the leaders of the organization or church program to provide and/or secure needed medical treatment for my child. In case of accident or injury, I release the leaders from all liability for providing or securing such treatment.

* Parent/Guardian Signature (type in name)

* Date

* Indicates Response Required

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