Permission Form

First Congregational United Church of Christ

Appleton, Wisconsin

2009-2010 UCC CONFIRMATION CLASS

LIABILITY RELEASE AND EMERGENCY MEDICAL CONSENT

NAME OF STUDENT: _________________________________________ 2009/10 Grade: _______

The purpose of this form is to allow my child to participate in ALL official trips of the 2009-2010 Confirmation

program of First Congregational UCC of Appleton, Wisconsin and to release the church, its staff and volunteer

chaperones of any liability against personal losses of named student.

I, _________________________, as parent/guardian of the above named youth, give my permission for

him/her to accompany pastors and/or recognized adult chaperones of my local church. Further, I hereby

release these individuals and First Congregational United Church of Christ of Appleton, Wisconsin from, and in

connection with, any claim brought by anyone arising out of the trips of the 2009/10 Confirmation program. I

AUTHORIZE EMERGENCY MEDICAL SERVICES DEEMED NECESSARY FOR THE YOUTH NAMED

ABOVE IN THE EVENT OF AN ACCIDENT OR INJURY, UNDERSTANDING THAT I WILL BE CONTACTED

PROMPTLY IF SUCH A SITUATION ARISES. I also acknowledge that I will be ultimately responsible for the

cost of any medical care not reimbursed by the health insurance provider.

EMERGENCY MEDICAL INFORMATION:

Insurance Company or Health Care Plan: ___________________________________________________

Employer Providing Insurance (or Self): ____________________________________________________

Group/Plan or Policy Number: ____________________________________________________________

Youth Participant Birth Date: ___________________________ Blood Type: ______________________

Prescription Drugs: _____________________________________________________________________

Medical Conditions or Allergies: ___________________________________________________________

_____________________________________________________________________________________

Physician’s Name________________________________ Physician’s Phone _______________________

EMERGENCY ADULT CONTACT:

Name: _____________________________________________ Home Phone: ______________________

Address: ____________________________________________ Work Phone: ______________________

____________________________________________ Cell Phone: _______________________

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I understand that any behavior unbecoming of Christian youth including, but not limited to, tobacco, alcohol, or

other illegal drug use or any sexual relations are grounds for the restriction and/or return of the youth from this

activity. I agree to bring my student home at my expense should he/she become ill or if deemed necessary by

the youth ministries staff member. I HAVE FILLED OUT THIS FORM TO THE BEST OF MY ABILITY, AND I

HAVE READ, UNDERSTAND AND AGREE WITH THE ABOVE INFORMATION.

Parent/Guardian Signature: _____________________________________ Date: _______________