EmailMe Form - PARENTAL RELEASE FORM

Participant Name *

First Last

Birthdate *

MM / DD / YYYY

Gender *

Male

Female

Non-Binary

Tee Shirt Size
(some service trips and other opportunities have a tee shirt available) *

Small

Medium

Large

Extra Large

Parent or Guardian *

First Last

Phone *

### - ### - ####

Cell Phone

### - ### - ####

Work Phone

### - ### - ####

Emergency Contact *

First Last

Emergency Contact Phone Number *

### - ### - ####

Insurance Company

Insurance Policy Number

Insurance Policy Group Number

Does your child have any health challenges that might affect his/her participation?

Special needs (if any)

Please list allergies (if any)

Blood Type (if known)

Date of last tetanus shot? (if applicable to the activity)

MM / DD / YYYY

I hereby give permission for my child to participate with the Montview Boulevard Presbyterian Church Youth Group from Sept. 1, 2015-August 31, 2016: *

MM / DD / YYYY

In the event of an emergency during the duration of the trip, I hereby give consent to a licensed physician to hospitalize, secure proper treatment, anesthesia and/or surgery for my child named above. I understand that I am responsible for his/her medical insurance and will not hold Montview Boulevard Presbyterian Church liable for any injury or damage to my child while engaged in the activity sponsored by Montview Boulevard Presbyterian Church.

Today's Date *

MM / DD / YYYY

Parent/Guardian Name *

First Last

Checking this box serves as your digital signature. *

Digital Signature