1790 Sequoia Boulevard
Tracy, CA 95376
Youth Youth Leader
Child’s Birthdate _________________ Age ________ Grade/Year _____________
I give permission for my above named child to join the ministries of Tracy Community Church for all outings scheduled and approved by the business office for the year of ___________. I must be properly informed of all the particulars relative to each outing.
I hereby release Tracy Community Church, its staff and sponsors from responsibility and liability for injury and illness that my child sustains during any activity. In the event of an emergency, I hereby authorize an adult leader of an activity, as an agent for me to consent to an x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to participate under the laws of the state where the services are rendered, at a doctor’s office or in any hospital. I expect to be contacted as soon as possible if any such emergency should occur.
I will also pick up my child or arrange for his/her transportation home at my expense if the staff or sponsor of Tracy Community Church ministries deem such action to be necessary in the discipline of my child.
Signature of Parents:
_________________________________________ _________________________________________
Father Mother
_________________________________________ _________________________________________
Emergency Contact Phone
_________________________________________ _________________________________________
Medical Insurance Co. Policy Number
_________________________________________ _________________________________________
Members name Employer
Allergies/Handicaps/Medications:
__________________________________________________________________________________________________________