|
GENERAL EVENT PERMISSION SLIP |
|
First Congregational UCC |
|
2503 Main Street, La Crosse, WI
54601 |
|
608-784-8137 |
|
| I give permission for
___________________________________ |
| to attend the event ___________________________________ |
| on ___________________________________
|
| sponsored by First Congregational UCC. I further grant
permission for a licensed physician chosen by the director of the event (if
necessary) to perform emergency medical treatment for my son/daughter,
including x-rays, prescription drugs or surgery. I will assume liability for
any resulting expense which is not covered by insurance. My hospital of
choice in La Crosse is: |
|
FRANCISCAN SKEMP
GUNDERSON LUTHERAN |
| Name of Physician:
________________________________________ |
| Date of Birth of youth: _______________________
Age: ________ |
| Health Insurance Company:
_________________________________ |
| Name of Policyholder:
_____________________________________ |
| Known medical conditions of allergies of which
we should be aware:
|
| During the event, I can be reached at: |
| work _____________ |
home _____________ |
cell _____________ |
| Other emergency contact person & phone number:
_______________________________________________________________ |
| Signature of
Parent/Guardian: ____________________________________
Date: ____________ |
