Youth Permission Slip

Child's Name:
Event:
Event Date:
Address:
City/Town:
State:
Zip Code:
Mother's Name:
Mother's Cell Phone
Mother's Email:

Father's Name:
Father's Cell Phone:
Father Email:

Emergency Contact information:
Emergency Contact #1 Name:
Emergency Contact #1 Cell Phone Number:
Emergency Contact #1 Home Phone Number:
Emergency Contact #1 Work Phone Number:

Emergency Contact #2 Name:
Emergency Contact #2 Cell Phone Number:
Emergency Contact #2 Home Phone Number:
Emergency Contact #2 Work Phone Number:

Allergies or Special Concerns:
Date of Last Tetanus:

Insurance Company Name:
Insurance Company Address:
Insurance Policy Number:

Family Physician:
Physician's Address:
Physician's Phone number:
Present Illnesses:
Present Medications:

Policy Holder:
State:
State:
Home Phone:
Work Phone:
Zip Code:

In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in the above event, every reasonable effort will be made to contact the persons listed on this form. If unsuccessful in contacting the persons listed, consent/permission is given for treatment by competent medical personnel. Further, and unless specified otherwise, consent/permission is hereby given to all accompanying adult volunteer leaders at this event to hospitalize, secure proper treatment for, and/or injection, anesthesia or surgery (under recommendation of qualified medical personnel).

I agree that my insurance company will be used for such medical care and expenses and I am aware that I may be billed by the medical provider for any medical treatment expenses not covered by my insurance. I understand that if I do not have medical insurance coverage that I am responsible for the payments of medical bills.

Sign: (Type Name):
Date:

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