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Valleypoint Students Name: ________________________ The Point Youth Group Student’s Cell# ________________________ 714 S Pines Rd. Spokane Valley, WA 99206 (509) 928-7880
To Whom It May Concern: As a parent or guardian, I authorize treatment by a qualified and licensed medical doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.
Planned activity:_____________________________________________________
Date of activity:______________________________________________________ Name of Minor: _______________________________ Date of Birth: _________ Address: _____________________________________Phone: _______________ City: ________________ State: _____________Zip______ Cell: _____________
Physician: ______________________________Phone: ____________________ Dentist: ________________________________Phone: ____________________
Person to call if I am not available: Name: _______________________________ Phone: ____________________ Relationship to Minor: ___________________Cell: _____________________
I hereby give my permission for my child, _________________________, to attend the Youth Event on (date) _______________To (location of event) _______________________________
I release Valleypoint and those acting on its behalf from responsibility for any accident and resulting injuries to the above mentioned child while traveling to and from, and while participating in this activity.
Parent/Guardian Signature: _________________________ Date: _________________ |
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RELEASE FORM! Directions: · Highlight the document. · Copy and paste into Word. · Complete the form. · Have a parent sign it. · Bring it to the event! |
