Permission Slip / Release Form

I do hereby give my consent for my child to participate in overnight activities/outings/or events in San Antonio and the state of Texas. I understand that this form gives my full permission for one (1) year beginning with the date I enter in the form below.

I have instructed my child on his/her conduct and responsibilities. I understand that if my child fails to comply with the rules established by the activity leaders, I will be notified and may possibly be required to provide return transportation of my child earlier than the expected return from the activity/event/outing.

I hereby release Resurrection Baptist church, its leaders, and organizers from all liability from personal injury to my child, as a participant and/or spectator. In the event all reasonable attempts to contact me have been unsuccessful, I give consent for immediate medical treatment as required, in the judgment of health professionals, while my child attends youth ministry sponsored activities.

I further understand that this form must be signed and returned to the RBC Activity Leader/Organizer before my child may participate in any recreational activities.

Click here for the printable form

YOUTH'S NAME(S)
Name*
First Last
Date Of Birth*
Month
Day
Year
Name
First Last
Date of Birth
Month
Day
Year
Name
First Last
Date of Birth
Month
Day
Year
Name
First Last
Date of Birth
MM
DD
YYYY
Name
First Last
Date of Birth
MM
DD
YYYY
PARENT/GUARDIAN CONTACT INFORMATION
Name*
First Last
Phone number 1*
Phone Number 2*
Email Address
FAMILY PHYSICIAN
Name*
First Last
Address*
Street Address City ZIP Code
Phone*
MEDICAL INSURANCE COMPANY
Name
Policy Number
Policy Owner
The following information is needed by any hospital or practitioner not having access to a medical history:
Allergies:
Medication being taken:
Physical Impairments:
Other pertinent facts to which physicians should be alerted:
Date of last tetanus shot:
MM slash DD slash YYYY
If parent/guardian cannot be reached in case of emergency, call
1st Choice* Name*
Phone*
2nd Choice* Name
Phone
Do you give permission for your child to receive Tylenol or Mortin as determined necessary?*
By submitting this form, you are giving your consent for your child to participate in overnight activities/outings/or events in San Antonio and the state of Texas.*

YOUTH'S NAME(S)

PARENT/GUARDIAN CONTACT INFORMATION

FAMILY PHYSICIAN

MEDICAL INSURANCE COMPANY

Campus LOcations

Mailing Address

Admin Hours

Phone

Fax

Email Address

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