​     840 Trenton Rd., Fairless Hills, Pa. 19030

PERMISSION FORM

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   I                                                                 give my permission for                                            

                                               Parent/legal guardian                                                                                                                                                Name of Youth

                

   to participate with other members  of the Sr. High Youth Group at



                   Name of the Event                                                     on                                             Date of the Event

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     In the un-likey event of an emergency, I give my permission for my child to be treated by an accredited physician in an approved emergency clinic or hospital.  I therefore designate the adult chaperones for the group with authority to act on my behalf and order appropriate treatment. 

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     I further release from any liability The Sr. High Youth Group and its officers and leadership in the event of any accident en-route, during, and returning from this event.





             

                      Signature of Parent / Legal Guardian                                                                        Date





                            Emergency Phone Number                                                                              Allergies

   

   

         Participation in church events implies permission to use your likeness in publicity.



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