EAST FAIRFIELD UNITED METHODIST CHURCH

To Who It May Concern:

______________________________________________________________ has my permission to go with the

group __________________________________________ on the following event _______________________

_______________________________ at the location of _______________________________________ on the

date of ________________________________________________.

______________________________________________                 ______________________   

(Parent/Guardian signature)                                                                             (Date Signed)

Phone number in case of emergency:

Where parent(s)/guardian may be reached during the event: ______________________________________________

Alternate contact in case parent(s)/guardian cannot be reached:____________________________________________

Do you have custodial issues which impact who picks up your children?_____________________________________

Medical/Health Information:

Allergies, medication, hay fever, insect bites, asthma, food, other: ____________________________________

_________________________________________________________________________________________

Other pertinent health history information: ______________________________________________________

_________________________________________________________________________________________

Does your child/youth have any condition that would prevent him/her from fully participating in this program?

If yes, please explain: (Specific activities/foods to avoid): __________________________________________

_________________________________________________________________________________________

List any medication to be taken during the event, which will be kept by the leaders during the event:

_________________________________________________________________________________________

Preferred Doctor ________________________________________________ Phone _____________________

Preferred Dentist ________________________________________________ Phone _____________________

Preferred Eye Doctor ____________________________________________ Phone _____________________

Preferred Hospital _______________________________________________ Phone _____________________

EMERGENCY MEDICAL AUTHORIZATION

I give my consent for emergency medical treatment by a certified fist aider. In the event that additional treatment is needed, the staff of the Emergency Room of the hospital listed above, or one closest to the event location, has my permission to treat my child/youth.

Parent/Guardian Signature ______________________________________________ Date_________________

Parent/Guardian Name (print) _________________________________________________________________

Address __________________________________________________________________________________

Phone (hone) (_____) _____________________________ (work) (______) __________________________

Hospitalization Plan and Group # ______________________________________________________________