Kerk Permission Slip

Evangelical Covenant Church of Elgin Youth Ministry program MEDICAL AUTHORIZATION FORM AND PARENTAL PERMISSION FORM Cost: 75 TIME: FRIDAY AUGUST 2 5:00 PM-MONDAY AUGUST 5TH 4:00 PM Event Name: UNDERGROUND SUMMER RETREAT Place: 4430 WEST STORMY LAKE ROAD, CONOVER WISONSIN 54519 Date(s): April 12-13 We will be traveling to Conover Wisconsin on Stormy Lake for our summer Underground Retreat.. -------------------------------------------- Signature of Parent or Legal Guardian Printed name of Parent or Guardian Date EMERGENCY CONTACT INFORMATION Parent/Guardian Phone Numbers Phone Type (Home, Mobile, etc.) Name(s) Street Address City State Zip Phone Numbers Phone Type (Home, Mobile, etc.) Other Emergency Contact Name(s) Relationship to Participant HEALTH CARE INFORMATION Participant Name: Physician Dentist Name Name Phone Phone Medical Insurance Company Dental Insurance Company Policy/Group Number Policy/Group Number Name of Policy Holder Name of Policy Holder Facts concerning the child s medical history including: allergies, medications being taken, and any physical impairments to which a physician should be alerted: What to bring on the summer retreat..