Excellent Covenant Powerhouse Ministries
4103 Zephyr Road, Killeen, TX 76543
Permission Slip
Parent Name__________________________________ Email Address: ___________________________
Home Address: ________________________________________________________________________
Home Phone: (
) _______________________ Work Phone: (
) _________________________
Cell Phone: (
) _______________________
I hereby grant permission for my child______________________________________________________
__________________ (Nickname) _______________________________________to attend Excellent
Covenant Vacation Bible School from 13 thru 16 June 2017 with adult leaders and youth of ECPM. I also
grant permission for my child to be transported on field trips from and returning to the sponsor site,
within a 25 mile radius. I expect and hold my child to be responsible for his/her own actions during and
while traveling to and from this event. I expect my child to be a cooperative member of my group so the
activities can be a wholesome means of fellowship. I have read the statement of responsibility above
and have talked or will talk with my child about it. The church and adult leaders are not held liable for
unwise choices that my child decides to make*.
Signed_____________________________________________
(Parent or Guardian)
Date____________________________
I hereby authorize my child to be released to the following individuals ONLY for pick up or in the case of
an emergency, if I am unavailable. I understand that if these individuals are not known to the staff,
proper Identification will need to be presented.
Name___________________________ Telephone__________________ Relationship_______________
Name___________________________ Telephone__________________ Relationship_______________
*_________By initialing here, you agree to WAIVE, RELEASE, AND DISCHARGE ECPM from any and all
liability, including but not limited to, liability arising from the negligence or fault of the entities or
persons released for death, disability, personal injury, property damage, property theft, or actions of any
kind which may hereafter occur to me including my traveling to and from this event. Our volunteers are
not licensed instructors. However they have been ordained by GOD and have the integrity and
characteristics to teach the youth within this community.
Excellent Covenant Powerhouse Ministries
4103 Zephyr Road, Killeen, TX 76543
MEDICAL RELEASE FORM
In case of emergency, I understand that every effort will be made to contact me. If I cannot be reached,
I hereby give the designated sponsor permission to act on my behalf in seeking emergency treatment for
my child ___________________________________ in the event that such treatment is deemed
necessary by the designated sponsor. I give permission to those administering emergency treatment to
do so, using those measures deemed necessary.
Date _____________________________ Signed ____________________________________________
(Parent or Guardian Signature)
If parents are not available, please call relative or persons below:
Name & Relationship:________________________________________ Phone (
Name & Relationship:________________________________________ Phone (
Name & Relationship:________________________________________ Phone (
) _______________
) _______________
) _______________
Are there any allergies or medical conditions (medications, drug reactions, food allergies, etc.):
_____________________________________________________________________________________
Any needed medication? Yes / No ________________________________________________________
If any medication is used other than OTC meds; they must be in a prescription labeled bottle and
provided with instructions.
INSURANCE INFORMATION
Name of Insurance: ____________________________________ Expiration Date: __________________
Name of Insured: ____________________________________ Contract #:________________________