PARENTAL PERMISSION FORM      Event:   IYC 2010  Date July 14- 19th

 I am the [PARENT OR LEGAL GUARDIAN of__________________________                   

I acknowledge that I have been informed that, as a member of the Youth Group of Sullivan Church Of God, Sullivan , IL. My child will participate in activities during the year 2010 which carry a degree of risk. The activities include swimming, boating, hiking, camping, field trips, sports, snow sports and other activities which the church may offer, such as skating, basketball, football, volleyball.  I give consent for my child to participate in these activities. I also state that my child is in good physical condition and has the necessary skills to participate safely in these activities.      Specifically, swimming Ability adv ( ) begin ( ) None ( )

MEDICAL AUTHORIZATION

I understand that the church will attempt to reach me in case of a medical emergency involving my child. If the church cannot reach me, I give my permission to the church to hire a Doctor, and I give my permission to the Doctor to provide the medical services he/she may deem necessary. I will pay for medical expenses so incurred.  I will give notice to the church if I feel there are any health considerations that would hinder my child’s taking part in any of the activities listed above

Child’s Name____________________________Date of Birth_____________

Address__________________________________________________

Home Phone________________ Work_______________Cell__________

Parent Signature ______________________ (print name>_________________________Date________

Health Insurance Provider_________________________________________________

Policy Number________________________________ Contact Numbers______________________

Church Leader in charge:  Pastor Kathy Prideaux