Crosswind Community Church
Permission Slip
41337 10th St. West Palmdale CA, 93551   Phone:(661) 272-4903

I certify that my child is in good physical condition and give my permission for him/her to participate in______________     _______________________________________ ON Date(s):____________________________). Should any illness or accident occur to my child during this activity, I will not hold the Church nor its agents, the church officers, or its members liable. I herewith, for myself, my heirs, executors, and administrators, voluntarily waive, release, and forever discharge any and all rights and claims for damages against Crosswind Community Church and/or Grace International in conjunction with any loss—physical, mental, or implied, received by me and arising from my child’s participation in this church activity. I give my permission for any photographs or videotape taken at this event to be used for publicity purposes in behalf of the church. 

Child’s (Children’s)Name_______________________________________________________________
Address_______________________________________________________________________________

Parents/Guardian’s Name________________________________________________________________ 

Day Phone # ________________________________ Other Phone #______________________________

Family Physician__________________________________________  Phone ______________________

Insurance Co.__________________________________________ Policy #_________________________

Preferred Hospital _____________________________________________________________________________

Known Allergies______________________________________________________________________

_____________________________________________________________________________

In an emergency, if parents cannot be contacted, notify:
Name                                                           Relationship                                     Phone # ______________________________________________________________________________________
•	The Crosswind Community Church Leader(s) [  ]May [  ] May not apply first-aid treatment until emergency personnel  and/or the family physician can be contacted.
•	The Crosswind Community Church Leader(s) [  ]May [  ] May Not use their own judgement in securing medical assistance and ambulance service in case the parents cannot be reached.
•	My Child/Children [  ]May [  ] May not receive medical attention by a licensed physician.
•	My Child/Children [  ]May [  ] May not be admitted to a hospital in case of an emergency.
(Parent/Guardian will be notified first if possible)
Parent/Guardian Signature__________________________________ Date_____________