Permission / Medical Release

I, _______________________________
the parent or guardian of
_________________________________
(students name)
do give permission to my son/daughter to
participate in the Elevate 2011 Conference.
Should emergency medical treatment be
necessary, I authorize one of the adult leaders
to act on my behalf and approve the
appropriate treatment.
Insurance Co._____________________
Policy # _________________________
Other medical information:
_________________________________
_________________________________
_________________________________
Emergency Contact Phone Numbers:
#1 Name/Phone Number
_________________________________
#2 Name/Phone Number
_________________________________
_________________________________
(Signature of Parent/Guardian)
Date ____________________________