Youth Permission Slip

SOUTHWEST CHRISTIAN CHURCH
PERMISSION SLIP & Medical release

I, the legal parent/guardian of

* Indicates required field

Child's Name *

First

Last

do hereby authorize Southwest Christian Church as agents to consent on my behalf to any medical procedure advisable by a physician licensed under the Medical Practice Act. I understand that Southwest Christian Church and the parties representing it cannot be held responsible for any injury that may occur or any illness that may be transmitted during the time my child is in their care. If my child has a discipline problem that cannot be solved through verbal communication, I understand that my child will no longer be allowed to participate in the event and I will be called to pick him/her up.

Event *

Date of Event *

Emergency Phone # *

Insurance Carrier *

Policy Number *

Optional - Upload Insurance Card *

Max file size: 20MB

Current Medications *

Allergies or Special Instructions *

Electronic Signature Consent *

I affirm that entering my Name and Date below and submitting this form constitutes an electronic signature of this form. By signing this Electronic Signature Consent Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I understand that my electronic signature is legally binding. By signing below, I accept the conditions of this agreement.

Parent/Guardian Name *

First

Last

Date *

Submit

SOUTHWEST CHRISTIAN CHURCHPERMISSION SLIP & Medical release

SOUTHWEST CHRISTIAN CHURCH
PERMISSION SLIP & Medical release