My son/daughter _________________________________________________ (full name)

has my permission to participate in the ________________________

sponsored by Butterfield Community Church from ____________________ through ______________________.

Signature: _____________________________________ Date: __________________________

In the event that our child ______________________________________ becomes ill or sustains an injury while on an authorized and chaperoned outing from Tanner Trails Community Church, I the undersigned, give my permission to those in charge to take whatever steps necessary to stop any bleeding and to administer first aid.

I also consent to an X-ray examination, anesthetic, medical (or dental) or surgical diagnosis and treatment and hospital care, and the administration of drugs or medicine to be rendered to my child under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon.

I release Tanner Trails Community Church and its agents from all liability in connection with the foregoing actions.

I understand that this consent will apply to all emergency situations present and future, and that a copy of this form is as valid as the original. This consent is to remain in effect until written revocation is made.

Date: _____________________________ Signature: __________________________________ (Parent or legal guardian)

Name of both parents/guardians: ___________________________________________________

Address: ____________________________________

Phone: __________________________ (Home)

Phone: __________________________ (Work)

List Any Special Health Problems:

_____________________________________________________________________________

_____________________________________________________________________________

Any medications? (Name/dose/prescribing physician)

________________________________________________________________________________________________________________

Regular physician: __________________________________

Phone: _____________________

Birthday of child: ________________________________

In the event we cannot be reached during an emergency, please contact:

Name: ___________________________________________

Phone: _____________________

Insurance Company and Policy Number: ___________________________________________

Please Return This Form To TTCC