Western Hills Christian Church Youth Group
Pursue Christian Teen Conference (PCTC) - February 27-March 1, 2015
Permission Slip:
Name of Student _____________________________________ Date of Birth ____________________
Name of parent / legal guardian _________________________________________________________
Address ___________________________________________________________________________
Home phone ___________________ Work ____________________ Cell _____________________
Emergency name and number __________________________________________________________
Medical Information
Insurance Co. & Policy # ______________________________________________________________
Allergies, Medications ________________________________________________________________
I hereby give permission for the above named youth to participate in PCTC, February 27-March 1, 2015.
I hereby release Western Hills Christian Church, its staff, and youth sponsors from responsibility and liability for any injury or illness that the above named young person may sustain during PCTC, February 27-March 1, 2015.
Additionally, I authorize an adult youth sponsor of Western Hills Christian Church to act as an agent for me to consent to any X-ray, examination, medical/dental/surgical diagnosis, treatment/hospital care advised and supervised by a physician/surgeon/dentist licensed to practice under the laws of the state in which services are rendered, either at a doctor’s office or at a hospital, in the event that I am not able to make those decisions for myself.
__________________________________________ _____________________________
Signature of parent / legal guardian Date of signature
Pursue Christian Teen Conference (PCTC) - February 27-March 1, 2015
Permission Slip:
Name of Student _____________________________________ Date of Birth ____________________
Name of parent / legal guardian _________________________________________________________
Address ___________________________________________________________________________
Home phone ___________________ Work ____________________ Cell _____________________
Emergency name and number __________________________________________________________
Medical Information
Insurance Co. & Policy # ______________________________________________________________
Allergies, Medications ________________________________________________________________
I hereby give permission for the above named youth to participate in PCTC, February 27-March 1, 2015.
I hereby release Western Hills Christian Church, its staff, and youth sponsors from responsibility and liability for any injury or illness that the above named young person may sustain during PCTC, February 27-March 1, 2015.
Additionally, I authorize an adult youth sponsor of Western Hills Christian Church to act as an agent for me to consent to any X-ray, examination, medical/dental/surgical diagnosis, treatment/hospital care advised and supervised by a physician/surgeon/dentist licensed to practice under the laws of the state in which services are rendered, either at a doctor’s office or at a hospital, in the event that I am not able to make those decisions for myself.
__________________________________________ _____________________________
Signature of parent / legal guardian Date of signature