PCCTripPermissionForm

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 back. SIGNED this day of _______________________, 20_________ __________________________________ Signature of Parent or Legal Guardian __________________ Relationship _____________________________ Print Name 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: _______________________________________________________________________ Group/Subscriber Number:_______________________________________________________________ Date Effective: ________________________________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Emergency Contact Person (if different from above): __________________________________________ Emergency Day and Evening Numbers:_____________________________________________________