2017 PARENTAL CONSENT and MEDICAL AUTHORIZATION LWCC and Take It Easy

2017 PARENTAL CONSENT AND MEDICAL AUTHORIZATION – LWCC and Take it Easy

General Information (please print)(Additional children’s names may be added on back.)

All information is kept confidential. However, any leaders involved with

your child will have access to this information.

Student Name ______Date of Birth ______

Check One: p VBS (K-5th Grade) p YOUTH CAMP (6th-12th Grade)

Father’s Name ______Mother’s Name ______

Email: Email:

Child’s Address______

Phone Number (H)______(Cell)______(W)______

List two emergency numbers ______

Family Doctor ______Doctor’s Phone No. ______

Insurance Co. ______Policy No. ______

Consent and Certification

I, the undersigned, being the parent and legal guardian of the child(ren) named within, do hereby consent to the participation of my child in all of the regularly scheduled activities for VBS and/or Youth Camp during the week of July 17th -21st , including outdoor activities, bible studies, live music, bon fire, swimming, hiking, sporting events, and any other activities customarily associated with the children’s programs. Further, I certify that my child is physically fit and adequately trained to participate in such events, including swimming (only for youth camp), except as noted below:

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Please list any necessary medical information that we need to be aware of concerning your child. (Allergies, medications, special diet, or any illness/injury that would prohibit participation in activities. You may also use the back of this form.)

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MEDICAL TREATMENT AUTHORIZATION

I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I authorize any one or more of the appropriate leaders at Living Word Community Church or Take it Easy Ranch Campground to make emergency medical care decisions on behalf of my child, if required by law or a health care provider. I understand that the church or campground will not be responsible for medical expenses incurred solely on the basis of this authorization. I agree to notify the church or campground in the event of any health changes, which restricts my child’s participation in any normal activity. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

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Signature of Parent/Guardian Date

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Signature of Parent/Guardian Date

Child(ren’s) Names (and address if different): Birthdate:

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