ALL SAINTS LUTHERAN CHURCH

MIDDLE AND HIGH SCHOOL YOUTH PROGRAM

FIELD TRIP AND EVENT PERMISSION FORM 2016-17.

By completing this Field Trip and Event Permission Form, I give permission for my son/daughter (print name of youth here) ______, to carpool, attend events and to work in the community with others from All Saints LutheranChurch. I understand that participating in All Saints events is a privilege, and my son/daughter will be informed of specific rules governing any events and be expected to honor and respect others in attendance. If my son/daughter is being disruptive or otherwise behaving badly, I will pick up him/her immediately upon notification. I realize All Saints events are drug, alcohol, and smoke free. Possession of, or being found in the presence of, any of these substances may result in removal from the event.

In case of emergency during an event, please contact (print your name or name of contact): ______

Best way to reach (cell/text/home phone?): ______

I grant permission for All Saints staff or adult chaperone(s) to take whatever steps may be necessary to obtain emergency care as warranted for the well-being of my son/daughter. These steps may include but are not limited to the following;

  • Attempts to contact a parent or guardian
  • Attempts to contact youth's physician
  • Seeking medical examination/treatment for injuries/condition by medical professional

Name of youth’s primary physician/medical contact: ______

Phone number for that doctor/clinic: of doctor/medical contact: ______

Name of health insurance company: ______

Medications being taken/dosage/frequency ______

List ALL Allergies (food/meds/pets/etc.) ______

List any special dietary needs, additional health, emotional or other conditions of which we should be aware: ______

Mysignature below indicates that I understand and agree to the policy and terms listed above and agree that any expenses incurred in necessary emergency or other medical treatment will be borne solely by our family’s medical insurance coverage and/or family. I will not hold any leader or All Saints Lutheran liable for any injury or accident.

Parent/Guardian completing form (please print name): ______

Parent/Guardian Signature ______Date______

Parent/Guardian email ______

Youth, please complete this portion:
Name you prefer to be called if different from your name above: ______

E-mail address (if you want to receive emails in regard to upcoming events at All Saints): ______

Cell phone:______

Ok if we text you? □ Yes□ No

I understand that participating in All Saints events is a privilege, and my parent(s)/guardian will be informed if I am being disrespectful, disruptive or otherwise behaving badly. They will pick me up from any event immediately upon notification.

Signature (youth) ______Date______

Please return these forms to All Saints at 2951 Chapel Valley Rd, Fitchburg, WI 53711