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Baptist Tabernacle Worms Permission Slip

This form is to be completely filled out and signed by a parent
or legal guardian before a child may participate in this event.

Please Print:
Parent or guardian name __________________________________________________________

Home Address ____________________________________________________ Apt. No. ____________

City ______________________________________________________ Zip ________________________

Home Phone __________________________________________ Alt. Phone _______________________

Please list everyone of your household who has your permission to attend Collinsville Baptist Tabernacle’s

Lasers & Pancakes – Friday, August 27, 2010

7pm – Midnight Cost: $20 + IHOP
Teen’s Name Relationship to you Age Date of Birth

___________________________ ________________ _______ _____________________

___________________________ ________________ _______ _____________________

Do any of the above have allergic reactions to any medications? Circle one Yes No
If so, please list their name(s) and the medication(s) to which they are allergic:

_____________________________________________________________________________________

Other Information: ______________________________________________________________________

I hereby give my permission for all listed above to attend this event and participate in all activities. I
understand that my child(ren) will be under adult supervision. I further understand that in signing this
permission slip, I release and hold harmless Collinsville Baptist Tabernacle, its trustees, officers,
employees, and any volunteers from any liability, past or future, fully and completely. I authorize the
executive staff or designated medical professionals to administer emergency medical assistance if I cannot
be reached.

Parent or legal guardian signature _________________________________________ Date ____________