Click here to download Youth Permission, Medical, and Photo Release Form 

WPC YOUTH PERMISSION SLIP

I give my child, ______________________________________________, permission to participate in all Youth Ministry activities, trips, and programs sponsored by Wimberley Presbyterian Church in Wimberley, Texas.

General Information

 Child’s name:___________________________________________________Birthday: ___/____/_________

Address:_______________________________________________________________________________________

(Street) (City)  (Zip)

 

Home Phone#:_________________________________Child’s Cell#: _______________________________

 

School attending:______________________________ Grade level:________________

 

Father’s name: ________________________________ Cell#:________________________________________

 

Mother’s name: _______________________________ Cell#: _______________________________________

 

I understand that the chaperones will use their best efforts to supervise; however, I also understand they are not responsible for loss of personal property or bodily injury.

 

Signature of Parent/Guardian: __________________________________________________________

 

Date: _______/_______/________________

 

During youth events, there will be photos taken for church use on the web site and/or slideshows.  Will you give us your permission to use these photos of your child, knowing that your child’s name will not be attached to these photos.

 

I give permission for WPC to use my child’s photo:

 

Signature of Parent/Guardian: __________________________________________________________

 

Date: _______/_______/________________

 

 

 

Medical Information and Emergency Release

In the event my child becomes ill, is injured or requires emergency medical attention of any kind, and I cannot be reached by phone, I authorize the adult chaperone(s) to make the necessary decision concerning emergency treatment.  I also give permission for my child to be transported to the nearest medical facility or hospital for treatment.  I understand that I will assume full responsibility for the payment of services rendered.

Parent/Guardian Signature:______________________________________________________________

 

Date: _____/_____/_____________

 

If a parent cannot be reached, please contact the emergency person listed below.

 

Contact: _________________________________________ Home #: _________________________________

 

Cell #: ____________________________________________ Relationship_____________________________

 

My child wears contacts lenses: YES____  or   NO_____

My child’s last Tetanus shot was administered on: _____________________________________

 

My child’s allergies to medications are: __________________________________________________

 

_______________________________________________________________________________________________

 

My child’s other allergies are:______________________________________________________________

 

________________________________________________________________________________________________

 

The medications my child takes on a regular basis are: _________________________________

 

________________________________________________________________________________________________

 

Other information about my child that should be known to healthcare providers is:

 

________________________________________________________________________________________________

 

Name of Child’s Physician: ________________________________________________________________

 

Physicians Office #: _____________________________________________

 

Medical Insurance Company: ____________________________________________________________

 

Phone #: __________________________________________

 

Policy #: _________________________________________ Group #: ________________________________