Youth Permission Slip

Please fill this out to give permission for your student to attend the Youth Fishing Trip on 9/14

Student Name

First Name

Last Name

Personal/Parent/Guardian Phone Number

(###)

###

####

Medical Information

Does your child have any allergies, medications or health concerns?

No

Yes

If yes, please explain:

Emergency Contact (Other than Parent)

Name

First Name

Last Name

Phone

(###)

###

####

Relationship to Child:

Trusted Person Who Will Pick You Up

Parental Consent & Liability Waiver

I give permission for my child, named above, to attend the Fishing Trip hosted by New Heights Church. I understand that reasonable precautions will be taken to ensure the safety of all children, and that adult leaders will supervise the event. I release New Heights Church, its staff, volunteers, and affiliates from any liability in the event of injury, accident, or illness. In the case of a medical emergency, I authorize the adult leaders to seek necissary treatment for my child. I understand that I will be contacted as soon as possible. Permission Agreement Signature:

Date

MM

DD

YYYY

Youth Permission Slip

1145 North Main street, MIlton, wv| Sunday @ 9AM &11am

304-743-1145