Longs Peak United Methodist Church

Parent Permission Slip

We,______________________, are planning a trip to_____________________________ on (date) ________________. We will be traveling by ___________________________

Time and place of departure_________________________________________________

Time and place of return ___________________________________________________

Leaders name and number __________________________________________________

Each child needs $ ___________________for expenses. Other equipment needed ________________________________________________________________________In case of emergency, the leader will notify (name)_______________________________ (phone)______________________, who will then immediately notify the parents. If you need to notify your child of an emergency this can also work in reverse.

Leader’s Signature_____________________________________________Date________

Tear off and parent keep for quick reference

Tear off and return to leader

My child, ______________________________has my permission to participate in ________________________________________________________________________

They are in good physical condition and are able to participate in this event. Indicate any health conditions which might affect your child’s participation: allergies, serious illness, operations or recent accidents: _______________________________________ ________________________________________________________________________

During the activity, I may be reached at:_______________________________________

Parent\Guardian Name _____________________________________________________

Phone numbers (Home) ____________________ (Work)__________________________

(Cell)_________________________Relationship to child_________________________

Address_________________________________city___________________Zip_______

In the event that I can not be reached Please notify Name_________________________

Phone_____________________ Relationship to child ____________________________

Parent\guardian Signature___________________________________________________

In the event of any serious injury or illness on the part of the child, the adult will make every effort to contact me. In the event I cannot be reached, I authorize the adult to sign such waiver, as may be required, to provide emergency medical, surgical or dental treatment should this become necessary.

Parent\Guardian Signature_______________________________Date_______________

To be given to the emergency contact person

Child’s Name _____________________ Parent ___________________Phone_________

Alternate Emergency Contact_________________________Phone__________________