Long Ridge Baptist Church Permission Form

Name of event: Spoken Conference:

Date of Event: Friday November 11, 2011
Destination: Bowling Green, KY
Estimated Time of Departure: Friday 5:00 P.M

Return: Saturday November 12 @ 9:00 P.M.

Student Cost: $25 will cover one night stay, conference cost, and food. Financial assistance is
available.
__________________________________________________________________________________________
Student / Participant Name ___________________________________________________________________
Date of Birth _____________________________________
Parent/Guardian

Name

Sex________________________________

_______________________________________________________________________

Home Address _____________________________________________________________________________

Home Phone ____________________________ Business Phone _____________________________________
Cell / Mobile Phone _________________________________________________________________________

I, _______________________________________, grant permission for _______________________________

Parent or Guardian Name

Child Name

to participate in the above named activity and I warrant that my child is in good health. In consideration of my
childs participation, I will not hold Long Ridge Baptist Church or its members liable in any way for any injury
sustained. I also give my permission for those adults in charge to obtain any medical care they feel is necessary
for my child.
MEDICAL INFORMATION:

Insurance Co. _____________________________

Policy # _________________________________
Medication my child is taking at present _________________________________________________________
Allergies _____________________________________________________________________________