FIRST PRESBYTERIAN CHURCH OF JOLIET

PERMISSION, MEDICAL AUTHORIZATION, AND RELEASE

OF LIABILITY

             I, the undersigned parent or guardian of _____________________, a minor, do hereby consent to said minor attending the following church function; ______________________________________.

            I do hereby release and absolve said FIRST PRESBYTERIAN CHURCH, its employees, agents, the sponsors of the function, and any church members from any and all liability for damages or personal injury caused to said minor as a result of his/her  participation in and travel to or from said function.

            I further agree to indemnify the FIRST PRESBYTERIAN CHURCH, its employees, agents, the sponsors of the function, and any church member for any damages or injury caused by said minor.

             I hereby authorize any necessary emergency medical treatment to be given to said minor, and specifically authorize any adult sponsor, attending physician, or hospital to consent to medical treatment for the minor which said sponsor, attending physician, or hospital may deem necessary under the circumstances.  The following information is provided and may be relied upon in an emergency:

Allergic Reaction to Medication__________________________

Chronic Illness__________________________________________________

Health Insurance Policy___________________________________________

Policy No. _______________________________________________________

Home Phone Number ______________________________________________

Emergency Phone Number__________________________________________

Signed:                                                                              ____________________________________

                                                                                          PARENT OF GUARDIAN

                                                            DATED:______________________