Permission for all EHCC Youth Group Activities: Fall '10-Summer '11

Medical Care Authorization : In case of medical or surgical emergency, after every reasonable effort has been made to contact me, the family physician, or the relatives or friends named below, I hereby give permission to the physician secured by the adult(s) in charge of the activity(ies), to hospitalize, to secure treatment for, and/or to order injection, anesthesia or surgery for my child. In the event that any such treatment is not covered by insurance applicable to the activities, I will pay the expenses incurred in such emergency treatment.

Disclosure: I understand the youth group leader/chaperone(s) will accompany my child on all activities. I also understand that the leader/chaperone(s) may be volunteers--not necessarily paid staff--and not trained professionals, and that the activities will involve the normal level of risk associated with youth group activities and/or field trips.  I hereby release Eagle Harbor Congregational Church, its staff, and its volunteer chaperones from any and all liability due to any injury, loss or damage to person or property during the course of my child's involvement with youth group activities.

I also understand that my child may be transported to and from an event by the youth group leader and/or other volunteers; I do not hold those drivers or EHCC responsible if any accidents occur.  In the event that my child gets a ride with another youth, I do not hold the youth group leader, any volunteers, or EHCC responsible.  Further, I acknowledge it is not the responsibility of EHCC staff or volunteers to make sure I am home if my child is to be dropped off at home. 

Parent's Responsibility : I will take the responsibility to see that my child is properly prepared for each activity, and I will inform the chaperone/leader of any physical, mental or other conditions of my child of which the chaperone/leader should be aware. I will also pick up my child at the appropriate time scheduled or give my child permission to be left unsupervised at the church.

Youth Name(s)____________________________________________            Birth Date _________________

Parent/Guardian _________________________________________________________________________

Address _______________________________________________________________________________

Home/Work/Cell Phone____________________________________________________________________

Emergency Contact __________________________________________                Phone _______________

Family Physician _____________________________________________               Phone _______________

Health Insurance Plan and ID Number _________________________________________________________

Date of last tetanus shot ______________________             Allergies ________________________________

Regular medication _______________________           Activity Restrictions ___________________________

Other Important Information ________________________________________________________________

I have read and understand the above statements.

Signature ___________________________________________________              Date ________________