PERMISSION FOR CHILD TO PARTICIPATE IN ACTIVITY

I / We hereby grant permission for my / our child, _________________________,

(Date of Birth: _____________) to participate in the following activity:

Activity Description and Information:

Event Sponsors:

Local Phone Contact (for out of town events):

In consideration for the advantages to my / our child, I / we release the First Unitarian Church, Louisville Kentucky, and its employees, volunteers, and other representatives from liability for any accident or injury to my / our child. In addition, I / we agree to hold harmless the First Unitarian Church, its employees, volunteers, and other representatives for any liability for injury to my / our child or for damage caused by my / our child to the extend not covered and paid by any liability insurance that may be in effect.

____________________________________

Signature, Parent or Guardian Date

____________________________________

Signature, Parent or Guardian Date

Please be sure the event sponsor has a completed Authorization for Medical Treatment.

AUTHORIZATION FOR MEDICAL TREATMENT

I / We authorize the First Unitarian Church, its employees, volunteers, and other representatives to provide first aid and to act as my / our agent to authorize any reasonable and necessary emergency medical care needed by my minor child _____________________________, (Date of Birth: ______________). I / We also authorize the administration of routine or prescribed medication as set out below:

Medicine Dose Time or Indication May Child Administer to Self?

Known Allergies or Sensitivity to Food or Medicine:

Significant Medical Conditions:

Health Insurance Company: _________________________________________________

Policy: _____________________________________

Member ID: _________________________________

Number to Call for Coverage Authorization: _________________________________

Child's Primary Care Physician: ___________________________________________

Telephone: ______________________

____________________________________ ____________________________________

Signature Date Signature Date

____________________________________ ____________________________________

Printed Name Printed Name

_____________________________________________ _____________________________________________

Address Address

____________________________________ ____________________________________

Telephone Telephone

Additional Telephone Numbers if not available at above:

Fuurepf – First Unitarian Church RE - Youth Group Permission Form – 10-09-2001.doc / fuu / rds / 10-09-2001