Permission And Release Form

Permission and Release Form Event Information Date

_____________________________________________________________

Event Description

_____________________________________________________________

Destination

_____________________________________________________________

Departure Time/Location

_____________________________________________________________

Estimated Time of Return

_____________________________________________________________

Means of Transportation

_____________________________________________________________

These adults will be accompanying the children for this event: _________________________Phone #__________

_________________________Phone #__________

_________________________Phone #__________

_________________________Phone #__________

-------------------------------------------------------------------------------------------------------------------------------

Event Permission As parent/guardian of ___________________________________, I understand that my child is to take the trip described above. I give permission for my child to participate and I release Capital City Church Assembly of God and its agents from any and all liability which may arise during or relating to the trip, except liability for damages or injuries caused by the sole negligence of Capital City Church Assembly of God.

____________________________________________ Signature of Parent/Guardian

______________________ Date

________________________________________________ Phone where I can be reached during the field trip

Medical Permission Please list below any medicine to be taken or medical care that will be necessary during or immediately prior to the event. _________________________________________________________________________________________ _________________________________________________________________________________________ By signing below, I am authorizing emergency medical treatment during this outing for the above named child, should it be deemed necessary by licensed medical personnel.

____________________________________________ Signature of parent/guardian

______________________ Date

Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614-442-1700 www.capitalcitychurch.org