Permission Slip Form

Permission Slip / Medical Release Form
Name:
Address:
City:	State:		Zip:
Phone:	Birthday:		Birthyear:
Emergency Person & Phone:
I (we) give my son permission to participate in all Trinity Battalion activities for the 2007-2008 academic year. I understand that, in the event medical treatment is required, every effort will be made to contact me. However, if I can't be reached, I give my permission to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child's well-being.
Parent/Guardian (signature):		Date:
Medical Problems:
Allergies:
Tetanus (date of last immunization):
Present Medical Treatment:
Current Medication and Dosage:
Insurance Carrier and Number:
Thank you for your help with this sometimes tedious task. It is our prayer that this form will be of no use to us on our trips, but in the event that we do need it, this information will be a great help.