The Church In Aurora -


My son/daughter/ward,		, has permission to participate

in
	(name of church activity),

and to be transported to and from said activity in private vehicles with drivers who are 21 years or older.

Please list any special medications, allergies, needs, etc.

In the event of an accident, I give my consent for emergency medical treatment for my son/daughter/ward in case of an accident or illness.


DATE		SIGNATURE OF PARENT OR GUARDIAN		PHONE NUMBER

Emergency Contact Info:

Name:

Phone:

Address:

Relationship:

Phone:

Physician’s Name:

Phone:

SERVING CHRIST AND COMMUNITY