The United Baptist Church of Ashford Living Proof Youth Revolution PERMISSION SLIP - Blank Date: __________________________ I, ______________________________, mother/father/guardian of__________________ grant permission for my daughter/son to attend __________ (function), in ___________ (location) with The United Baptist Church of Ashford. I understand the children will leave from United Baptist Church and will be transported by Van and or Car . I have health / medical / hospitalization insurance coverage for my child and agree that is primary to any coverage that the Church might carry. I know of no allergies to foods or drink that my child has except…_____________________________ nor does she/he need any special care except…______________________________________________. Health Provide_____________________________ Policy #___________________________________ Primary Physician _________________________Town_________________ I recognize that this activity is for the benefit and enjoyment of my child and is part of the ministry of the United Baptist Church of Ashford. I may be reached at _______________________________(phone number) in case of an emergency. If I am not available you can contact _________________________(name). at ______________________________________(phone number). I give my authorization for the chaperon to seek any medical assistance he/she deems necessary in the event of an accident or illness to the above named child. ______________________________________________________ Mother/Father/Guardian Activity leaders may be contacted directly in case of emergency at Pastor Patrick McCue 860 377-0314
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