Millbury Federated Church Youth Group Permission

Millbury Federated Church Youth Group Permission\Commitment Form

On this the______ day of___________________, 20____, I give permission for_______________________________ to attend___________________________________________ on _________________ with the Millbury Federated Church Youth Group. I further give permission for any Youth Group advisor or responsible adult acting in behalf of the Youth Group and any emergency response personnel to render emergency aid to my child if such a need should arise, and will not hold the advisor, responsible adult, emergency response personnel or the Millbury Federated Church financially responsible in any way for any such aid they render. I further give the advisor, responsible adult and emergency response personnel permission to seek treatment for my child, should the need arise, at the nearest hospital or medical treatment facility. In case of emergency I may be reached at: ____________________________________________________ My child’s Primary Care Physician is: _________________________________PH_________________ Insurance coverage may be verified by calling: _______________________________________________ My insurance policy number is: _____________________________________________________ Please list another emergency contact person and phone number:

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Signed, Parent\Guardian

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************************************************************************************ YOUTH’S COMMITMENT TO ATTEND EVENT
[ ] I commit to attend the above event and with this form I am enclosing the full payment of _______________.
Or
[ ] I commit to attend the above event and will pay in installments. One third of the total amount due is included with this form.

Signed, Youth Participant .

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