United Parish of Auburndale Youth Ministry – Ski Trip-2016
PARENTAL/GUARDIAN CONSENT FORM AND LIABILITY WAIVER
PARTICIPANT’S NAME: _________________________ BIRTH DATE:____________ Cell Phone # ________________
HOME ADDRESS:________________________________________E-mail Address_ ___________________________
HOME PHONE:______________________EMERGENCY PHONE_____________________ Cell Phone: ______
My Child, _______________________________, has my permission to attend and to participate in the United Parish of Auburndale youth ski trip February 19-21, 2016, sponsored by the United Parish of Auburndale. I represent that my child is healthy and capable of participating in said event without causing risk of danger, illness or accident to themselves, or to others. I agree to hold harmless the leaders of my church, the event coordinators, the Pastor and volunteers in the event of any accident or injury.
In the event that my child requires medical attention while attending the event, I understand that an adult sponsor of the event will make every reasonable attempt to contact me. In the event that I cannot be contacted, I consent to any medical attention deemed appropriate. In the event that treatment is called for, which the medical provider refuses to administer without consent, I hereby authorize an adult sponsor to give such consent for me if I cannot be contacted immediately or, because of an emergency, there is no time or opportunity to make contact. In the event that it is necessary for that person to give consent, I agree to hold such person free and harmless of any liability for damages arising from giving such consent.
I declare that my child is covered by medical insurance and/or that I am responsible for any and all expenses incurred by my child whether covered under insurance or not.
(NOTE: THE SPONSORS OF THIS EVENT DO NOT PROVIDE INSURANCE IN CASE OF INJURY OR ILLNESS).
Custodial Parent or Legal Guardian Signature: ______________________________________
Relationship to Participant __________________
FAMILY DOCTOR: ____________________________________________________________________________
FAMILY HEALTH PLAN CARRIER:________________________________________________________________
Policy Number:_______________________________ Group #______________________ Ins Phone:__________________
Allergies to medications and reaction: ________________________________________
Medications sent with participant:
Note: Prescribed medications must be in original pharmacy container with the correct name, date, instructions and physicians name on label. Over the-counter medications must be in original container and have dosage information clearly printed on container. Please notify the event coordinator if this participant has been exposed to any communicable disease within the 3 weeks prior to this event. Participants will NOT be allowed to attend if they arrive at the event ill. Are there any over-the-counter medications that
the participant should not receive if any minor symptoms develop? (i.e. Tylenol, Advil, Kaopectate, etc.)
(Please provide a copy of both sides of insurance card)