TEENS FOR CHRIST NW
914 Citadel Dr. #D
Everson, WA 98247
Birth date ___________________ Age ___________ Phone # ________________________
Mailing Address _____________________________________________________________
City _________________________ State ________________ Zip _____________________
School _______________________________________ Grade ________________________
Parent(s) business or cell phones _________________ (dad) ______________________(mom)
Email Address _______________________________________________________________
To whom it may concern:
The undersigned does hereby give permission for our (my) child, ____________, to attend and participate in the outings sponsored by Teens for Christ for the school year of 20___-20___. We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray exams, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnoses or treatment is rendered at the office of a physician or at a hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
The undersigned does also hereby give permission to our (my) child to ride with any adult in whose care the minor has been entrusted.
Father’s name _______________________________ Mother’s Name _____________________________
Legal Guardian _______________________
Hospital Insurance? Yes No
Insurance Company ___________________________ Policy Number _____________________________________
Signature of Guardian ____________________________________________________ Date ___________________
Please list any allergies or special medical problems your child has _________________________________________