Permission Slip

Bennett Memorial United Methodist Church & Olive Branch

Emergency Release / Permission Form

Please fill out the form and hit submit button below.

You will need to fill out a form for each child.

Child's Name:

Parent's Name:

Parent's Email

Child's Birth Date:

Child's Social Security Number:

Age:

Grade:

Address:

Address or Apartment Number:

City: State: Zip:

Home Phone: Cell:

Work Phone: Other:

In Case We Cannot Reach You Whom Should We Call Next:

Name:

Phone:

Name:

Phone:

Insurance Company:

Policy Number:

Special Medical Information:

I give my permission to go and participated with Bennett Memorial United Methodist Church on their trip to , I fully understand the dangers and risks involved in the activities that my child will be participating in and will assume all Responsibility of injury in connection with them, releasing and discharging Bennett Memorial United Methodist Church and the counselors/sponsors involved with their trip, of responsibility. In case of emergency, I hereby give permission to the physician selected by the leaders to hospitalized, secure proper treatment for, and to order injection, anesthesia, or surgery for my child, as named above, if I cannot be immediately reached guaranteeing payment of such treatment.

Electronic Signature of Parent or Guardian:

Date: