To Sierra Evangelical Lutheran Church:

PERMISSION AND MEDICAL RELEASE FORM

I give permission for my child, _____________________________ to participate with

other youth from Sierra Ev. Lutheran Church for _________________________(event).

In case if emergency I can reached at :_____________________________(home phone)

or ____________________ (work phone) or _______________________(cell phone).

If I cannot be reached, the following person can be contacted to act on my behalf:

__________________________________________________ (Name and relationship)

Home Phone:_________________________   Work Phone:_______________________

Physicians Name and Phone Number:_______________________________________

Known Allergies:_________________________________________________________

Last Tetanus Immunization:_________________________________________________

Family Medical Insurance Company:__________________________________________

Insurance Policy Number:___________________________________________________

If I cannot be reached in the unlikely event of an emergency, I give permission for my
child to be treated by and accredited physician in an approved medical clinic or hospital.
I, therefore, designate adult chaperons for the group with the authority to act on my
behalf in order to obtain treatment.  I further release from any liability Sierra Evangelical
Lutheran Church in the event of any accident en route, during, and returning from this event.

AND

I understand that if my child is found using alcohol, drugs, or illegal substances
I will be contacted and expected to get him or her immediately.

___________________________________                                         ____________
(Signature of parent or legal guardian)                                                (date)