Name of Participant____________________________________________________________

Address______________________________________________________________________

Birthday________________________________Phone#_______________________________

Person to contact in emergency__________________________________________________

Telephone_______________________

I give my permission for my child to attend and be transported to and from the designated activity. I also grant my permission for the leader of this activity to exercise authority in my behalf for treatment in case of a medical emergency. I understand that the above named person will depart for this activity from:

Fill in departure time and place and return time and place in this area.

I also herby release FOG Depot Student Ministries from any liability.

Signed____________________________

Date______________________________

Please list any allergies, medications being taken, medical problems or other pertinent information we should know.

_____________________________________________________________________________