FIRST PRESBYTERIAN CHURCH OF WAUNAKEE PERMISSION TO PARTICIPATE

Student name:

Date of Birth:

Has my permission to travel with the First Presbyterian Church of Waunakee Youth Ministry Teams on Saturday August 13, 2011. I hereby authorize Thomas Burris and the other adult advisors traveling with the group to care for any medical emergency that might arise with my child on August 13, 2011 while my child is participating in this event. Parent or Guardian Signature: Other Emergency Contact: Home phone: Parent Name(s): Address: Home Phone: Parent Name(s): Address: Home Phone: Insurance Company: Health Policy Number: Primary Care Physician: Physician Phone Number: Any food related allergies: Any allergies to medications: Any allergies to insect bites: Medical conditions: Date: Work phone: Cell Phone:

Work Phone: Work Phone: Work Phone: Work Phone:

Cell Phone: Cell Phone: Cell Phone: Cell Phone:

Medications you will bring (please include dosage and frequency):

If your child requests Tylenol, Advil, or other pain relieving medication, please list the dosage and frequency that they may have it:

Date of last Tetanus Shot: