Permission Slip Form - Please fill out completely and press submit

Event    

Date of Activity    

Name   

Address      

Birth Date     

Home Phone #     

Emergency Contact Name   

Emergency Contact Number     

I (we) release my child into the custody of the supervising adults to participate in the above named activity. We hold Dakota Ridge Assembly blameless for any accident and/or injury suffered while participating in the planned activity.  In case of emergency, I hereby give permission the attending physician or emergency personnel to secure proper treatment, including hospitalization and/or necessary surgery, for my child. It is understood that a conscientious effort will be made to locate the Emergency Contact listed on this form. I/we will fully pay for all medical expenses incurred.

Signature   

Date   

Please list any allergies, health problems, medications or other pertinent health information.