First United Methodist Church
of Fairless Hills
840 Trenton Road - Fairless Hills, Pennsylvania 19030 Phone: 215-946-5800
Reverend Gary Dimovitz
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
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.
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.