I ______ Hereby Grant Permission for ______ to Attend the First Presbyterian Church Of

FIRST PRESBYTERIAN CHURCH YOUTH GROUP

LIABILITY RELEASE AND EMERGENCY CARE AUTHORIZATION

I ______hereby grant permission for ______to attend the First Presbyterian Church of Quincy Youth Group Island Hoping Beach Adventure o August 10, 2011.

In the event an emergency should arise, I grant permission to those in charge to do whatever is deemed necessary to insure her/his safety and well being, and I hereby authorize in advance any medical care deemed necessary. I agree to be held responsible for any such medical expenses. I have completed the medical information listed below and agree that my child is authorized to take the medications listed below. (over-the-counter or prescription)

I also have discussed the rules (see below) with my child, and we both realize that failure to follow them could result in his/her removal from the retreat and/or my child being sent home at my expense.

______

Signature of parent or legal guardian Date Signed

EMERGENCY MEDICAL INFORMATION

In the event of a medical emergency, we will require certain information. Please provide the following:

______

Emergency Contact Phone Number

______

Health Insurance Provider Policy Number

The youth is taking the following medication (over-the-counter or prescribed) at the time of the retreat. Please inform adult volunteers of any medication to be taken by your child during the retreat (if none, so state). Additionally, please list any know allergies:

YOUTH AGREEMENT TO RULES:

1.  Alcohol, tobacco, illegal drugs, weapons, violence or sexual activity will not be allowed under any circumstances. No use of drugs of medications without prior notification to and permission of youth leaders. Abuse of even legal drugs will be considered illegal drug use.

2.  ANY inappropriate, demeaning, derogatory or offensive behavior will be unacceptable.

3.  Adult volunteers rely on the cooperation of each youth in all instances, particularly when on the road. All our youth are expected to obey the instructions given by adult leaders on all trips and events.

I have read and understand the rules of all First Presbyterian Church trips and events and I understand that the consequences of failing to follow them could include my removal from the retreat or event. I agree to help promote a positive community.

______

Signature of Youth Date Signed