Permission forms and medical forms
These forms are offered as samples only. I am not qualified to offer legal advice, nor am I qualified to give advice on how to comply with your insurance carrier's rules. Please consult your insurance carrier, your congregation's legal counsel, and your congregation's board before using any of these forms.
Medical form and consent-to treat
Permission for off-site field trips
Permission for on-site overnights
Whichever forms you use may be three-hole punched, and mailed to parents in advance with a description of the field trip or overnight (having PDF versions of the form on your Web site is also a good idea). It may be a good idea to print forms on your congregation's letterhead. Forms are collected when children/teens are dropped off for the event (have blank copies on hand for parents/guardians who have forgotten theirs). Collect forms and store in a three-ring binder; that three-ring binder is carried by the adult leaders at all times during the trip; or kept accesible during the entire at-church overnight.
Many lawyers will say that parents/guardians should fill out a permission slip and medical form for each and every trip; so-called "blanket" permission slips may be useless. Please consult your congregation's legal counsel for his/her opinion based on your state or local laws.
Medical release and Consent-to-treat form
Unitarian Universalist Church of Valhalla
Rev. Pray Alot, Minister
Hardy Soul, Director of Religious Education
1 Church St., Valhalla, MA 01799
978-555-5555
www.uuvalhalla.org
Name of child/teen: __________________________________
Home address: __________________________________
__________________________________
City: __________________________________
State: __________ ZIP: ____________
Date of birth: __________________________________
Name of legal guardian(s): __________________________________
Address (if different than child): __________________________________
__________________________________
Home phone: _____________________________
Cell phone: _________________________
Please list an alternate emergency contact if we cannot reach the legal guardian:
Name: __________________________________
Phone: __________________________________
Relationship: __________________________________
Primary care physician: _____________________________________
Phone number: __________________________________
Health insurance carrier: __________________________________
Policy number: __________________________________
Subscriber: __________________________________
Effective date: __________________________________
Medical history for emergencies, including date of last tetanus shot:
Current medication used (if any):
I give my permission for my child to receive any needed medical care and treatment required in my absence. I understand that I will be responsible for any expenses not covered by my insurance carrier.
Signed: __________________________________
Date: __________________________________
Please print name: __________________________________
Relationship: __________________________________
Permission slip for off-site field trips
Unitarian Universalist Church of Valhalla
Rev. Pray Alot, Minister
Hardy Soul, Director of Religious Education
1 Church St., Valhalla, MA 01799
978-555-5555
www.uuvalhalla.org
My child, __________________________________, has my permission to go on a field trip off church property to __________________________________.
I understand the group will leave from the church at approximately (time ) _______________, and return to the church at approximately _______________. During this time, I can be reached at this telephone number: _______________.
The adult leaders going on this trip will be:
__________________________________ .
Signed: __________________________________
Date: __________________________________
Please print name: __________________________________
Relationship: __________________________________
Please also fill out a Medical release and Consent-to-treat form. Thank you!
Permission slip for overnights at church
Unitarian Universalist Church of Valhalla
Rev. Pray Alot, Minister
Hardy Soul, Director of Religious Education
1 Church St., Valhalla, MA 01799
978-555-5555
www.uuvalhalla.org
My child, __________________________________, has my permission as parent or legal guardian to stay overnight on church property while I am not present.
I understand the overnight begins at the church at approximately (time ) _______________, and will conclude at approximately _______________. During this time, I can be reached at this telephone number: _______________.
Please list any food allergies: __________________________________
The adult leaders staying on this overnight will be:
_____________________________________ .
Signed: __________________________________
Date: __________________________________
Please print name: __________________________________
Relationship: __________________________________
Please also fill out a Medical release and Consent-to-treat form. Thank you!