EAGLE HEIGHTS CHURCH

CROSSWALK KIDS MINISTRY

PERMISSION SLIP

I, ____________________________, give permission for ________________________ to attend _____________________ on __________________, 2008. Participation in church events offers many benefits but I also acknowledge that participation in church-sponsored events involve certain risks and hazards of injury and/or property damage, and may result in my child being unable to contact me or to receive immediate medical care and assistance if injury occurs. I further agree to indemnify the Eagle Heights Church, staff and volunteers, for any and all damage or injury that my child may cause to result of his/her participation in church-sponsored events. I release and waive any liabilities against Eagle Heights Church, its staff, and volunteers. I agree if my child is not behaving in a manner consistent with the church regulations on good conduct, is not following event rules or is being disrespectful to adults in charge of event, that my child may be excluded from participation in any or all church events. I acknowledge that these activities may include, but are not limited to, activities both on or off church property, during day or evening hours, requiring transportation by motorized vehicles and occasionally may involve overnight stays. Such events and activities may include and involve the preparing and eating of food, using candles and fire, or being around them, using scissors and other tools, and using arts and crafts supplies and other materials. Some events may involve recreational and sports activities such as, but not limited to, hiking, climbing, baseball, basketball, swimming, games, trampoline, and frisbee. We will not hold any other organizations liable as it pertains to these trips.

I do hereby authorize adult workers with the children of the above named church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services.

Insurance Company or Group: __________________________________________

Policy Number: ______________________________________________________

(Please print the following information)

Name of Participant: __________________________________________________

Name of Parent or Guardian: ___________________________________________

Home Phone #: ( ) ___ ___ ___ - ___ ___ ___ ___

Mobile/Pager Phone #: ( ) ___ ___ ___ - ___ ___ ___ ___

Emergency Phone #: ( ) ___ ___ ___ - ___ ___ ___ ___

______________________________________ ____________________

(Signature of Parent or Guardian) (Date)

My signature confirms that I hereby give witness to the proper completion of this form by the minor’s parent or guardian.

*** Please list anything that might limit your child from participating in activities as well as any allergies or medical needs including medication that may be needed on activity below or on backside. If you do not want your child/teen participating in particular activities (i.e. jumping on trampoline) please list that as well.