Permission Form

Permission, Transportation & Health Form

I give permission for my child (youth participants)/I agree (adult participants) to be transported and particpate

in all activities relating to ____________________________________________

on (dates) ________________________________.

In case of emergency, I understand that every effort will be made to contact parent(s), guardian(s), or other relatives listed below. If these contacts cannot be reached, I hereby give the staff and appointed volutneers permission to act on my behalf in seeking emergency treatment for my child/me in the event that such treatment is deemed necessary. I give permission to those administering emergency treatment to do so, using those measures deemed necessary. I understand that Zion is not responsible for related injuries that may occur during this event.

Name of Participant ____________________________________________________________

Address________________________ City _______________________ State _______ Zip__________

Insurance Company ______________________________ Insurance Co. Phone ________________________

Insurance Co. Address __________________________________________________________________

Policy Number ____________________________ Policy Holder's Employer ___________________________

If parent/guardian/spouse is not available, please call person below:
Name _____________________________ Phone(H) _________________(W)_________________

Relation_____________________________________ Address _________________________________________

I give permission for over the counter pain medication to be given as needed to the participant. Additional comments regarding medical history allergies, current prescriptions or drug reations, etc., that may be needed in treatment or helpful for staff:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Participant Signature ____________________________________________________________

Signature of Parent/Guardian _______________________________________________________