ROOTED Ministries

TRIP Permission Slip and Medical Consent Authorization Form

 

(We) I the undersigned parent(s) or legal guardian(s) of:  NAME: _________________________________

                                                                                                                        (Please print minor’s name.)

a minor, do hereby authorize representatives of the LAS FLORES CHURCH OF THE NAZARENE, Carlsbad, California, as agent(s) for the undersigned, to consent to any emergency diagnostic procedure and any medical or surgical treatment required and deemed advisable by any duly licensed physician and surgeon, or under this or her general or special supervision.  It is understood that this authorization is being granted for emergency medical and/or surgical care only, and that all usual means shall be used to notify the undersigned prior to commencement of any major procedure.  It is understood that such specification shall not prohibit the institution of such emergency care as is necessary to preserve the life of the above minor.

We (I) further do attest approval of this authorization and do certify as to its correctness, expressly waiving any and all claims against the LAS FLORES CHURCH OF THE NAZARENE, Carlsbad, California, or any of its Boards or representatives because of the injury or other damage that may be incurred to the above minor or said minor’s property in connection with any incident during the trip.

Further, I hereby grant permission for the above name child to participate in the  LAGOON WAKEBOARDING/ BOATING ACTIVITIES  which will take place in __SUMMER  2008  .

I understand that this trip will be taken by ( x) auto ( x) van ( x ) boat (  ) bus (check one.)  I further understand that an authorized adult will be in charge at all times and will take necessary measures to the best of his or her ability for the protection of health and safety of the group.

 

X ____________________________________________                                 ________/________/___­___

                 Signature of Parent or Guardian                                                                                    Date

 

________________________________________________________        (         )   _______ - __________

                                Address                                                                                                             PHONE

 

EMAIL :___________________________________________________                                                (         )  _______ - __________

                                                                                                                                                                                                  CELL

In case of emergency notify:

 

______________________________________________________            (         )   _______ - __________

Please Print Name                                                                                                                 PHONE

 

______________________________________________________

Address

 

Special Medical Conditions of Minor, such as DIABETES, ALLERGIES, etc. _______________________

 

______________________________________________________________________________________

 

Medication Currently Using: _______________________________________________________________

 

Insurance Info:

 

Insurance Company Name _____________________________________ Policy # _____________________

 

Doctor’s Name __________________________________________             (         )   _______ - __________

Please Print Name                                                                                       Phone

 

Please make checks out to LAS FLORES CHURCH.