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Permission forms for overnight trips
For the 2006-2007 church year.
Please print out, fill out, and sign both forms for any overnight trip. These forms cannot be submitted via email as we need to have signatures.
Permission slip for overnights
This form must be filled out for all legal minors (under age 18) going on overnight trips.
My child, ________________________________________________ ,
has my permission as parent or legal guardian to go on an overnight trip:
___off church property to: ______________________________ OR
___on church property.
I understand the group will leave from the church at approximately (time ) ________________ ,
and return to the church at approximately _______________ .
During this time, I can be reached at this phone number: _____________ .
Please list any food allergies: _________________________________
Please list any medication to be taken during this time: ________________________________
The adult leaders going on this overnight will be _____________________________________ .
These adult leaders are either paid staff members or screened volunteers.
Signature: _____________________________________
Date: ______________________
Please print name: _______________________________
Relationship: ___________________________________
Please also fill out a Medical release and Consent-to-treat form. Thank you!
First Unitarian Church in New Bedford
Rev. Dan Harper, Minister
71 8th St., New Bedford, MA 02740
508-994-9686 -- www.uunewbedford.org
Medical release and Consent-to-treat form
This form must be filled out for all legal minors (under age 18) going on overnight trips.
Name of child/teen: ________________________________________
Home address: _____________________________________
City: ___________________________________
State: __________
ZIP: ____________
Date of birth: ________________________
Name of legal guardian(s): __________________________________
Address (if different than child): ______________________________
Home phone: _____________________________
Cell phone: _________________________
Please list an alternate emergency contact if we cannot reach the legal guardian:
Name: ____________________________________
Relationship: ________________________
Primary care physician: _______________________________________
Phone number: ______________________________
Health insurance carrier: _________________________________________
Policy number: ___________________________
Subscriber: _________________________
Effective date: ___________________________
Medical history for emergencies, including date of last tetanus shot:
Current medication used (if any):
I give my permission for my child to receive any needed medical care and treatment required in my absence. I understand that I will be responsible for any expenses not covered by my insurance carrier.
Signed: _______________________________________
Date: ________________________
Please print name: _______________________________
Relationship: __________________
First Unitarian Church in New Bedford
Rev. Dan Harper, Minister
71 8th St., New Bedford, MA 02740
508-994-9686 -- www.uunewbedford.org