Moppets Information & Permission Slip

Child’s Name: ________________________________________________________________________

Address: _____________________________________________________________________________

City, State, and Zip: ____________________________________________________________________

Phone: ____________________________ Age: ____________ Birthdate: ________________________

Parent/Guardian: ______________________________________________________________________

I, the parent/guardian of __________________________, do hereby authorize the adult sponsor of this MOPPETS program bearing this written authorization, into whose said care the above mentioned minor child has been entrusted, to obtain proper medical care from a licensed medical or dental doctor or facility, in the case of an emergency. The medical/dental care is to include, but is not limited to, any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which the aforementioned physical or dentist in the exercise of his best judgment may deem advisable. This authorization shall include transportation to receive the medical or dental care.

FINANCIAL RESPONSIBILITY

In the event of injury or illness to my child/ward, I agree that my health care insurer and I shall be financially responsible for any medical treatment required by my child/ward as a result of any injury or illness suffered during his/her participation in any MOPS related activity.

RISK

(Pertaining to athletics, games, travel, hiking, climbing, projects, weather, hobbies, and other related activities) I am aware that these activities may involve some hazard. I have considered these risks and I still wish my child to participate. In consideration of my child/ward participating in these activities, I agree not to bring legal action against Calvary Evangelical Free Church, staff, sponsors and/or volunteers as a result of any injury suffered in the course of my child/ward’s participation.

MEDICAL INFORMATION

Medical Insurance Company: _________________________________ Policy #: _______________________

Doctor’s Name: ____________________________________________ Phone#: _____________________

____ Drug/Food Allergies ____ Diabetes ____ Hay Fever ____ Insect Stings/Allergies

____ Nervous Disorder ____ Asthma ____ Chronic Asthma ____ Epilepsy

____ Cardiac Problems ____ Physical Disorder ____ Emotional Disorder ____ Seizure

If you checked any of the above, please give details: ___________________________________________

___________________________________________________________________________________

Emergency Contact Person: _______________________________________________________________

Phone #: _______________________________ Relationship: ___________________________________

I have supplied all of the above information. I have read and understand the terms of this agreement.

Signature of Parent or Legal Guardian: _________________________________ Date: ______________