Parent Consent Form for Group Activity and Medical Authorization The child named below has permission to participate in a day trip to Valley Fair Amusement and Water Park on June 9th, 2023. We will leave at 6 am and return around 10 pm. Drop off and pick up is at the church. * First Name Last Name Email * Phone * (###) ### #### Participant's Date of Birth * MM DD YYYY Do you have Health Insurance? Yes No If yes, Policy Name of Health Insurance Company: Has participant had any of the following? (check all that apply) Frequent or severe headaches Ashma Ear, nose or throat trouble Heart trouble Dizziness or faiting spells Frequent colds Shortness of breath Diabetes Please list any medical conditions not listed above: List Allergies and/or Allergic Reactions: List any medication your child currently takes: Should it be necessary for participant to have medical treatment while participating in this activity, I hereby give the person(s) in charge permission to act on my behalf to get participant medical services deemed necessary and appropriate by the physician. I absolve Breckenridge Lutheran Church from any and all forms of negligence and wrong treatment incurred in the procurement and process of hospitalization and medical treatment. I understand any cost incurred shall be my responsibility. (Your typed signature below will be your written signature.) * Relationship to Participant * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country 2nd contact in case above is unreachable: * Phone * (###) ### #### Thank you!
