North Park Covenant Church Youth Group
Permission/Release Form- Six Flags- 2013
Participant’s Name __________________________________________ Age _______
Address _______________________________________________ Phone _______________
City _____________________________ State __________ Date of Birth _______________
School __________________________________________________ Grade _____________
Does your son/daughter have any medical problems or allergies that we should know
about? YES _____ NO _____ If yes, please explain.
Is your son/daughter on any medications? YES _____ NO _____
If yes, please describe the kind of medication, dosage, frequency and administration by
whom authorized.
EMERGENCY CONTACT:
Name ______________________________________________ Phone ___________________
Address _____________________________________________________________________
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I give permission for my child to participate in the North Park Youth Group trip to Six
Flags: Great America, Gurnee, IL on Wednesday, July 17, 2013 from approximately 10:00
AM to 9 PM. The children will be traveling by bus from the North Park Parking Lot and
will be returning to the same. I hereby waive and release any and all rights and claims for
damages, which I may have against the church, and all of their agents, servants and
employees, for any and all injuries which my child may incur while taking part in your
program. This release also encompasses any injuries which may be sustained while
traveling to and from participation in your program. As a parent I understand it is my
responsibility to pick up my child at the predetermined time. I also understand that if my
child becomes ill or destructive, the above “EMERGENCY CONTACT” will be called to
take my child home.
In the event of an emergency, I hereby authorize Elise Brimhall or any other adult
chaperone on this activity to sign/consent to any X-ray examination; medical, dental or
surgical diagnosis: treatment; and hospital care advised and supervised by a physician,
surgeon or dentist (as appropriate) licensed to practice in the state where services are
rendered, either at the doctor's office or in any hospital.
____________________________
_______________________
___________
Parent/Guardian Signature
Parent/Guardian Print
Date
____________________________
Adult Participant Signature
_______________________
Adult Participant Print
___________
Date
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