(Child's name) ______________________________________________________________
Address___________________________________________________________________
Telephone Number _______________________ Insurance Co. ______________________
Policy # __________________ Cell phone or pager # _______________________________
I give permission for my child to attend ___________________________________________.
In the event of illness or accident, I authorize the Sunnyside Foursquare Church Staff or leaders
to
provide emergency medical care by a local medical doctor or hospital.
(In the case of an emergency we will make every effort to contact you.)
Parent or Guardian _______________________________________ Date ____________
Medical Information: Is your child on medication? If so, please describe:
_______________________________________________________________________
Does your child have any medical conditions? ____________________________________
Food allergies- __________________________________________________________