Permission Slip

As parent or guardian of the minor named below, I hereby authorize my child to participate in the following activity being conducted by the Corinth Missionary Baptist Church Youth Ministry(required)
Date: (required)
Time:(required)
Cost:
I hereby release and discharge CMBC and their adult youth advisors and volunteers for any damage, losses, or injuries to person or property that may be sustained while participating in these activities. I, the undersigned parent or legal guardian of the minor named below, authorize treatment and/or hospitalization that is necessary in the case of accident or illness of my child by a licensed medical physician. However, every attempt will be made to reach me by telephone prior to any treatment. In the event that I cannot be reached in an emergency, I hereby give my permission to the licensed physician or dentist selected by the church leader to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for my child as deemed necessary.
Name of Youth(required)
Address(required)
City(required)
State(required)
Zip(required)
Phone(required)
Emergency Contact
Name(required)
Phone(required)
Health Information
Any current health conditions we should be aware of? If yes, please explain.
Medications?
Allergies?
Health Insurance Company
Insurance group #
Insurance ID#
Family Doctor & phone:

This form and others are also available for download to print for your personal records.

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