Permission form due date is 10/2/11

1. TJ Sr. Youth Group Event Permission Slip
Visit to First Unitarian, Sunday October 9th
Permission Slip Due Date: Sunday, October 2nd
Event Destination: First Unitarian Church
Starting Time and Place: 10:15 AM, SHARP FOR CARPOOL FROM TJUC
Ending Time and Place: 3:00 PM, TJUC
Adult Sponsors for this event:
Name: BARB FRIEDLAND Phone 425-6943 (CELL 548-5006)
Name: (2nd person pending) Phone: _____________________________
Additional Information: TJUC youth are invited to attend a youth led service at
First U about their recent Youth Mission Trip to New Orleans. Please bring a
sack lunch, labeled with youth’s name, including beverage (refrigeration is
available). There will be a weather dependent service project outdoors afterward.
Youth should dress for outdoor conditions.
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(Please detach above for your records & turn in below portion on or before the due date)
First Unitarian Visit, Sunday October 9th
I give my consent for my child, _______________________________, to participate
in the above mentioned event sponsored by _TJUC , I understand that the
church does not accept responsibility for any bodily injury incurred during this
event. I give permission for any emergency medical, surgical, diagnostic and
hospital care, treatment, and procedures to be performed by a licensed physician
or hospital when deemed immediately necessary or advisable by a physician to
safeguard my child’s health when I cannot be contacted. I agree to be responsible
for any expenses not covered by my insurance, which may be incurred as a result
of an accident or medical emergency involving my child.
Parent/Guardian Signature: ________________________________ Date: ________
PLEASE ATTACH COPY OF INSURANCE INFORMATION to this sheet.
My child has the following allergies, dietary restrictions, or medical conditions:
(please use back of sheet if need) _______________________________________________
________________________________________________________________________
Emergency contact information:
Primary - Name: __________________________ Phone: H: ____________________
Cell: _________________________
Secondary – Name: __________________________ Phone: _____________________