Original filename: PCCTripPermissionForm.pdf
Author: Bonnie Douglas
This PDF 1.3 document has been generated by Pages / Mac OS X 10.5.8 Quartz PDFContext, and has been sent on pdf-archive.com on 12/09/2011 at 21:53, from IP address 64.207.x.x.
The current document download page has been viewed 993 times.
File size: 49 KB (1 page).
Privacy: public file
Download original PDF file
Crossroads Church Middle School
Permission/Registration and Release Form
I hereby give my consent for
following activity of Crossroads Church, Newnan, Georgia:
to participate in the
Passion City Church Trip
I understand that insurance coverage for accidental injury or sickness will not be provided by Crossroads
Church and I agree that I will be responsible for any medical expenses that might be incurred because of
accident or illness.
I hereby release Crossroads Church, Newnan, Georgia, its agents, employees, or volunteer workers from
any liability for accidental injury or sickness which may occur to the above person while participating in
the above activity, including transportation to and from. I also give my consent to the sponsors to
authorize emergency medical treatment for the above participant while trying to contact me at one of the
phone numbers listed.
If the above person is required to leave in advance of the time when any furnished transportation leaves,
either for medical reasons or for discipline reasons, then I agree to arrange and pay for the transportation
day of _______________________, 20_________
Signature of Parent or Legal Guardian
Home Phone: ________________________________ Cell Phone: _______________________________
School: _________________________ Circle One: Member – Attender - Visitor of Crossroads Church
Parent Email(s): _______________________________________________________________________
If applicable, I am listing any Medical Problems or Allergies:
Name & Phone Number of Doctor: ________________________________________________________
Name of Insurance Company: ____________________________________________________________
Group Name: _________________________________________________________________________
Policy Number: _______________________________________________________________________
Date Effective: ________________________________________________________________________
Emergency Contact Person (if different from above): __________________________________________
Emergency Day and Evening Numbers:_____________________________________________________