FIRST UNITARIAN CHURCH OF HAMILTON
YOUTH PERMISSION FORM AND

 AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I,___________________________, give permission for my son/daughter to participate in the following adult supervised activity:

                                                   Event:_______________________

                                                    Location: _________________________

_________________________

 The activity will take place on ________________________ from ________________________to ___________________________. We will be departing from, and returning to the church.

ą I give permission for my son/daughter to be transported to and from the event by reasonable and safe means. I understand that youth advisors will remain with the youth at the church until all youth have been picked up. (Please give details on the back of this form if your son/daughter will not be picked up by you, but will be responsible for returning home from the church at the end of the event on his/her own)

 OR

ą My son/daughter will be transported directly to Laser Mania and will arrive at ________pm_ and be picked up at _____________ pm by (name) _____________________________

I agree and hereby do release and hold harmless any and all adult supervisors for the activity, from and for any and all liability which may arise for damages, loss or injuries, either to person or property, which my son/daughter may sustain while engaged in the activity conducted, including, but not limited to, any damages, loss or injuries that may be sustained through transportation to and from the activity .

Should any injury occur, I give permission for my son/daughter to receive emergency treatment from an appropriate health care provider to be selected by the adult supervisor of the activity, when, in such supervisor's opinion, the need for such treatment is immediate, and when efforts to contact me (us) are unsuccessful. I also agree to pay and be responsible for all medical, hospital or other expenses which may be incurred as a result of securing such treatment.

I further agree to assume responsibility for any liability which may arise for damages, loss or injuries which may be caused or contributed to by my son/daughter to the person or property of others while travelling and/or participating in this event.

I understand that church safety policies require that two responsible adults be in attendance with youth at all times, and that therefore, youth must travel together and remain together at the event location in order for youth advisors to adhere to this policy.

Signature: ____________________________________Date:___________________________
Home address: ________________________________Email___________________________
Home phone number:___________________ Emergency phone number:_________________
Family Physician/Practice:_______________________ _______________________________
Physician's phone number:_______________________
Health Insurance Number __ __ __ __ __ __ __ __ __ __ Version Code ___ ___

Additional Information you wish to share about your son/daughter which might be required in case of emergency: (eg: current medications, medical conditions, drug allergies etc)

 ___________________________________________________________________________________

Other needs__________________________________________________________________________

____________________________________________________________________________________