PERMISSION AND MEDICAL RELEASE FORM
Christian Service Brigade 2047 - Stockade - Battalion - Tree Climbers
The Wesleyan Church of Orchard Park 2010 - 2011
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Boy's Information
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(Circle Group) - Tree Climbers - Tuesday Stockade - Wednesday Stockade - Battalion - JL
Boy’s Name __________________________________________Birth Date ___________________________
Street Address ____________________________________________________________________
Town, State, Zip __________________________________________________________
Phone Number ____________________________ Cell or 2nd Number ________________________________
Parent Email (for notices, send home letters, etc) ________________________________
Parent’s/Guardian’s Name ______________________________________________________________________________________
Are there any custody issues or situations we need to be aware of? _____No _____Yes, contact me (or see Jim Szczodrowski)
ALLERGIE’S OR SPECIAL CONDITIONS _____________________________________________________________________
If there is additional information or circumstances that may be of benefit for us to know about your boy, please use the back of this sheet. All information is kept confidential.
I, ______________________________________________ give my permission to _______________________________________________ to participate with other youth, leaders, helpers and chaperones name of minor(s) from the Wesleyan Church of Orchard Park, Brigade 2047 both on and off the premises at 7295 Ellicott Road, Orchard Park, New York to be held during the period of September 6, 2010 until September 5, 2011. In the unlikely event of an emergency, I give my permission for ____________________________________________ to be treated by an accredited physician in an approved emergency clinic or hospital. I therefore designate officers, leadership and any adult chaperones for the group with the authority to act on my behalf and order appropriate treatment. I further release from any liability the Wesleyan Church of Orchard Park, Christian Service Brigade 2047, and its officers, leadership, chaperones and participants in the event of certain accident or mishap enroute, during, after and/or returning from activities of the Wesleyan Church of Orchard Park.
parent(s) or legal guardian(s)
Parent/Guardian Signature ___________________________ Medical Insurance Company & Policy Number for above Minor
Date_____________Phone __________________________ Other Contact Name/Number in Emergency
Family Physician Name/Number ____________________________________________________________________
Other Contact Name/Number _______________________________________________________________________
Youth Small - Youth Medium - Adult Small - Adult Large - Adult X Large - Adult XX Large
Note: The t-shirts shrink, go at least one size larger. Sizes needed to be ordered in batches of 6. If not enough boysorder a size they will receive the next largest size. Order will be placed the week of 10/5 -boys returning slips after order is placed will receive the closest size shirt we have.
rev.8/10