Permission Slip 

AUTHORIZATION OF CONSENT TO TREATMENT OF MINOR  & LIABILITY RELEASE

AUTHORIZATION OF CONSENT TO TREATMENT OF MINOR  & LIABILITY RELEASE

I the undersigned, parent(s) of _______________________________, a minor, do here by authorize Gateway Fellowship, SBC and its representatives as an agent for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization  is given in advance of any specific diagnosis, treatment, or hospital care being required and is given to provide authority and power on the part of our aforesaid agent to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgment  may deem advisable.

No activities are without the possibility of unforeseen hazards.  Certain activities have the inherent possibility for risk, therefore, we want to alert parents, guardians, and individuals to them.  By signing this form the parent, guardian, or individual agrees to assume and accept all risks and hazards inherent to camping or in any activity with this group.  They also agree not to hold any of the counselors, chaperones, or Gateway Fellowship, S.B.C. liable for damages, losses, or injuries to the person(s) or property undersigned.  The parents or guardians understand that they are signing for minor(s) listed on this form and that the signature is for both medical and liability release.

Name _____________________________  Age______ Birth Date__________

Address________________________________________________________

City ______________________ State ___________________Zip Code______

Home Phone_____________________ Other Phone______________________

In Emergency, Notify_________________________ Phone ________________

Family Doctor ______________________________ Phone ________________

Health History:   

_____Drug Allergies     _____Frequent Stomach Upsets     _____Other Allergies

_____Hay Fever            _____Frequent Headaches               _____Heart Condition  

_____Insect Bites         _____Physical Handicap                   _____Epilepsy or other disorders

_____Asthma                _____Diabetes                                    _____Kidney Trouble

If any of the above are checked, please give details ___________________________________

__________________________________________________________________________

Date of last tetanus shot________ Name and dosage of any medications that must be taken daily.______________________________________________________________________

Any swimming restrictions: ___No ___Yes.  Any activity restrictions: ___No  ___Yes. What restrictions?_______________________________________________________________

Do you have Health Insurance? ___No ___Yes  Name of Company______________________

Policy Number_____________________ Main Insured Social Security #_________________

I have carefully read this agreement and fully understand its contents.  I am aware that this is a release of liability and indemnity and that it is a legally binding contract between Gateway Fellowship, SBC and me and I sign it of my own free will.

These authorizations shall remain in effect for one full year from the date signed unless sooner revoked in writing by the undersigned.

Parent or Guardian Signature___________________________________Date_____________