Bahamas Youth Mission Trip
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Participant’s Name (exactly as it appears or will appear on passport): _______________________________________________________________________ |
Participant’s Email: ________________________________________________________ |
| Parents’ Names: __________________________________________________________ |
| Parent’s Email: ___________________________________________________________ |
Emergency Contacts and Phone Numbers (during the trip): _______________________________________________________________________ |
Secondary Emergency Contact and Phone Number: _______________________________________________________________________ |
Medical Insurance Company and Policy #: _______________________________________________________________________ |
Date of Last Tetanus Shot (you will need a booster if not within five years): _______________________________________________________________________ |
Allergies: _______________________________________________________________________ |
Medications: _______________________________________________________________________ |
Special Medical Info or Instructions: _______________________________________________________________________ |
| I give my permission to allow my son/daughter to participate in Wilton Congregational Church's youth mission trip to The Bahamas. I also give my permission for the adult leaders of this trip to provide medical attention to my child in case of a minor injury and to seek the services of a licensed physician in case of an emergency. I agree to have my child sent home at my expense if he or she is found possessing alcohol, illegal drugs, tobacco, or weapons. I recognize that there are hazards associated with this trip and agree to hold harmless the Wilton Congregational Church and its employees and volunteers should there be an injury to my child. |
Signed by Parent or Legal Guardian: _______________________________________________________________________ |
Date: __________________________________________________________________ |