Permission Slip

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Download [PDF 32k] of the LCC Permision Slip

Lutheran Church of the Cross
28253 Meadow Drive
Evergreen, CO 80439
(303) 674-4130

Permission Slip/Medical Release Event

Name:__________________________________

Event Date:___________________________________

____________________________ (name) has permission to attend this event with Lutheran Church of the Cross.In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Youth Group/Church sponsors to hospitalize and secure proper treatment for my child as named above.

Emergency Information

Parent's Name ____________________________________________________

Address _________________________________________________________

Phone ___________________________________________________________

Your Physician ____________________________________________________

Physician's Phone __________________________________________________

Insurance Co. ____________________________________________________

Group # _________________________________________________________

Allergies to Medicine ______________________________________________

PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD,
FRONT AND BACK, WITH THIS FORM

If not available in case of emergency, notify:

Name ________________________________________________________________

Relationship __________________________________________________________

Phone _______________________________________________________________

Signature of event participant ___________________________________________

Signature of parent or guardian __________________________________________