General Permission Slip: We like to have this form on file for all youth participating in Lovely Lane programming so that if an emergency arises, we are prepared. This form must be filled out once per school year unless information changes. If information changes, please update the form and get it to Pastor Clint.

PARENTAL CONSENT FORM

Name __________________________________________

Age ___________________________________________

Birth Date _______________________________________

Address ________________________________________

Phone __________________________________________

City, State, ZIP code ______________________________

School Grade or just completed _______

(_____) ___________ (_____) ________________
Phone numbers where parents may be reached

To whom in may concern:

The undersigned do hereby give permission for our (my) child,

__________________________________, to attend and participate in
(Name of Child)
activities sponsored by the Lovely Lane UMC.

We (I) authorize the Lovely Lane Youth Leaders, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist 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.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Lovely Lane United Methodist Church.

Hospital insurance ________ Yes ________ No

Insurance Company______________________________

Policy Number _________________________________

Physician’s Name_______________________________

Physician’s Phone _______________________________

Emergency phone numbers ________________________

Participant, if age 21 _____________Date___________

Father _______________________ Date ____________

Mother ______________________ Date _____________

Legal Guardian ________________Date ____________

Please list any allergies or special medical problems your child may have.

Adapted from Fast Forms for Youth Ministry,
copyright 1987 Group Publishing Inc.,
PO Box 481, Loveland, CO 80539-0481