St. Christopher's EYC Permission Slip
YOUTH
Youth name *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Address *
Your answer
City / State / Zip *
Your answer
Primary phone
Your answer
Phone type
Secondary phone *
Your answer
Phone type
Email
Your answer
PARENT(S)/GUARDIAN
Parent(s)/Guardian name *
Your answer
Address *
Your answer
City / State / Zip *
Your answer
Primary phone *
Your answer
Phone type
Secondary phone
Your answer
Phone type
Email *
Your answer
MEDICAL INFORMATION
Allergies
List any allergies and allergic reactions (i.e. Epi-pen needed, etc.)
Your answer
Medications taken
List any medications your child is currently taking (i.e. inhaler, etc.)
Your answer
Medications to avoid
List any over the counter medications your child is not permitted to take should symptoms develop (i.e. headache, upsetstomach, etc.)
Your answer
Medical Insurance *
Name of Insurance Company
Your answer
Policy number
Your answer
Physician name *
Your answer
Physician phone *
Your answer
EMERGENCY CONTACTS
Primary contact name
Your answer
Relationship to youth *
Your answer
Primary phone *
Your answer
Secondary phone
Your answer
Secondary contact name
Your answer
Relationship to youth
Your answer
Primary phone
Your answer
Secondary phone
Your answer
AUTHORIZATION
By clicking submit we (I) hereby give permission for our / my child, to attend and participate in activities sponsored by St. Christopher's Episcopal Church.

We (I) also authorize the adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision, and on the advise of any physician or dentist under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. We (I) shall be liable and agree(s) to pay all cost to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

We (I) also hereby give permission for our (my) child to ride in any vehicle designed by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the church.

We (I) also understands that pictures and videos may be taken at church events and gives consent for said pictures and videos to be used for display/ promotion of church programs via print or church related websites.

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