Eastgate Christian Fellowship

CRASH & Grommets Youth Group

I give my permission for: ___________________________ (son/daughter's name) to participate in the ___________________________ with the Eastgate youth ministry on _______________________ (date) and agree to the following guidelines:

1. I hereby give my permission for medical attention to my student in the event of injury, illness or accident, including major surgery.  I realize I will be contacted at the earliest possible moment in case of such an accident.

2. I hereby release Eastgate Christian Fellowship, and the representatives of the church from liability in case of accident. 

3. I hereby request that the youth leaders carry out discipline, if necessary, and that I will pay the expense of my student being sent home due to disciplinary action.

Signature of Parent: _____________________________________

Home Phone:  ___________________________   Work Phone: ________________________   Cell Phone: _____________________

Address: _____________________________________  City: _______________________  Zip:____________________

Any medication required:  Yes   No   (circle one)

If yes, what medication? ________________  How often? ______________________________

Any allergies to medications?  Yes   No  (circle one)

If yes, what? _____________________________________