Parents are responsible for ensuring that Berlin Baptist Church has the most current information regarding their son or daughter.
A new Annual Permission Formis requiredif, at any time, there are any changes to the following:
Health Insurance Carrier
Policy Number
Date of Last Tetanus Injection
Current Medications
Special Medical Instructions
Emergency Contacts
This document will be kept on file and used in the event of a problem or emergency for your son or daughter while they attend and participate in our events/activities.
Sendto:
Berlin Baptist Church
Student Ministries – (Linda Smith)
P. O. Box 190
Wagener, SC 29164
Or Email to:
Questions? Call Linda Smith at 803-894-7273
Youth Ministries
ANNUAL PERMISSION SLIP FORM 2011-2012
For Berlin Baptist Church Sponsored Youth Events
Student’s Name ______Grade ______
Event Name: See attached list of Events on back of this form. Place: Various
Dates 09/01/2011 through 08/31/2012 Mode of Transportation: Church Bus
*This Permission Slip is valid only for the dates indicated above.
Student’s Health Insurance Carrier ______Policy Number ______
Birth Date _____/_____/_____ Last Tetanus Injection Date _____/_____/_____
Current Medications ______
Allergies ______
Special Medical Instructions (please attach separate sheet if necessary) ______
______
Emergency Call May Be Made To (full name) ______
Whose Phone Number Is (including area code) ______
(Student’s Name)______has the permission of the undersigned to participate in the activities indicated above. This form is effective from September 01, 2011 through August 31, 2012. In the event of an emergency affecting the health or welfare of this participant, the sponsors, leaders, or adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the parents or guardians of the participant. Insurance afforded by Berlin Baptist Church of Salley is an excess insurance, over any and all valid and collectible insurance coverage available to or for such person, as expressly named above.
Signature of Parent/ Guardian ______Date _____/_____/_____
Parent/ Guardian’s E-mail Address______
Berlin Baptist Church
Youth Ministries
424 Crossthorn Road
Salley, SC 29137
Linda Smith 803-530-8437, Joan Walling 803-530-1245 or Church 803-564-6308
Event Date / Event Name / Event Location / Event Time9/25/2011 / Breakfast / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 / 10:00am to 11:00 am
10/1/2011 / Corn Maze / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Farmer Sease’s Pumpkin Patch, Lexington SC 29072 (803)730-2863 / 4:00 pm to 9:00 pm
11/19/2011 / Lights Before Christmas / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Riverbanks Zoo, Columbia, SC 29210 (803)-779-8717 / 4:00 pm to 9:00 pm
12/3/2011 / Christmas Party / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Columbia, SC / 4:00 pm to 9:00 pm
1/7/2012 / Need God To Win It / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 / 4:00 pm to 8:00 pm
2/4/2012 / Valentine Party / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 / 4:00 pm to 8:00 pm
3/3/2012 / Back to Nature / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Congaree National Park, Hopkins, SC 29061 (803)-776-4396 / 11:00 am to 4:00 pm
4/7/2012 / Movie and Dinner / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 / 4:00 pm to 8:00 pm
5/5/2012 / Ice Skating Party / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Plex Indoor Sports, Irmo, SC 29063 (803)-732-1900 / 11:00 am to 4:00 pm
6/2/2012 / Out of School Party / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to 362 Crossthorn Road, Salley, SC / 4:00 pm to 8:00 pm
7/7/2012 / Fishing Trip / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Brown Pond Road, Wagener, SC 29164 / 4:00 pm to 8:00 pm
8/4/2012 / Shopping Trip / Berlin Baptist Church, 424 Crossthorn Road, Salley, SC 29137 and will travel to Concord Mills Mall, Concord, NC 28027 (704)979-3000 / 9:00 am to 9:00 pm