FIRST Presbyterian Church of inverness Yearlong Permission Form/Medical Release 2011-2012 School Year

206 Washington ave, inverness, FL 34450, (352) 637-0770

Youths Name

Youths Date of Birth / /

Parents/Guardians Names

Youths Phone Number (Is this a cell, home?)

Parents/Guardians Phone Number DAY NIGHT

Youths E-mail (if different than parent)

Parents E-mail (list all where you would like to receive e-mail)

Youth Mailing Address:

Secondary Emergency Contact:

Secondary Emergency Contacts Phone Number:

Are there any medical (physical or mental) needs that we need to be aware of (allergies, medication, etc.) Are there any special dietary requests? Attach additional paper if needed.
Health Insurance Carrier (or none if uninsured) Insurance Policy Number (group number)

Policy Members Name

Assumption of Risk Agreement and Release

I hereby give the above named student permission to participate in all activities, trips, and events of First Presbyterian Church for a period of time not to exceed one year from the date of this form above. I understand that such events may take place away from the church facility, and may involve transportation in church-owned or privatelyowned vehicles driven by staff, volunteers, or representatives of the church. I agree to release, hold harmless, and absolve First Presbyterian Church, its officers, staff, and volunteers, individually or collectively, from responsibility and liability for any illness, misadventure, harm, loss or inconvenience suffered or sustained by me or the student as a result of my students participation in any activity. I understand that in the event the named student requires medical treatment while engaged in church activities, that reasonable effort will be made to contact me or the emergency contacts named above. However, if they cannot be reached, I authorize a representative of First Presbyterian Church to obtain any necessary medical treatment, including x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care supervised by a licensed physician. I further agree that I shall assume full and complete responsibility for any expenses or costs involved in connection with the providing of medical services for the student.

I have read and understand the foregoing Assumption of Risk and Medical Authorization. Todays Date: Print Name: STATE OF FLORIDA COUNTY OF CITRUS Parents Signature:

The foregoing instrument was acknowledged before me this ___ day of ________, 20____, by _____________________, who is personally known to me/who has produced _____________________ as identification and who did not take an oath.

_________________________________ NOTARY PUBLIC