Permission slip 2021-2022

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* Student's Information:

Name: *

School: *

Grade for 2021/2022: *

Address: *

City: *

Zip Code: *

Home Phone: *

Student E-Mail:

Student Cell Phone:

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* Please fill in Health Information Below:

Student's Health Insurance Carrier:

Parent's Name who coverage is under:

Insurance Policy Number:

Student's Birth Date:

Doctor's Name:

Doctor's Phone Number:

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* Please fill in Health Information (if none - please type none in the boxes):

Current Medications:

Medicine Allergies:

Food / Health Allergies:

Any special medical, physical or behavioral instructions:

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* The student I listed above has the permission of the undersigned to participate in Redeemer Student Ministry events where he/she is driven by someone other than his/her parent or guardian. This form is effective from June 1, 2021 – May 31, 2022. In the event of an emergency affecting the health or welfare of this participant, the directors, leaders, or adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the participant, or parent/guardian of the participant. The undersigned hereby releases and discharges Redeemer United Methodist Church and all of its directors, leaders, and adult chaperones acting officially from any and all claims, demands, actions, or causes of action on account of any injury sustained by the participant. If any conduct of the participant warrants them to be excused from an event, the undersigned assumes all responsibility for disciplinary action and picking up said participant upon being notified by the director, leader, or Adult Chaperone. Should it be necessary for the participant to return home due to any reason, the undersigned hereby assumes all transportation costs. No student will be able to transport another student from Redeemer to an event that is held off site. Furthermore, I/We give Redeemer UMC permission to photograph my student while he/she participates in any activity and will allow these photos to be used for promotional purposes (including website, Facebook, Twitter, or Instagram)

By typing your name below you have agreed to all of the above informaiton

Type Parent First and Last Name here

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* Mother's Information:

Name:

Email Address:

Phone Number:

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* Father's Information:

Name:

Email Address:

Phone Number:

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* In the event that I/We can't be reached, an emergency call may be made to the following person:

Name:

Phone Number: