Beach Party Permission Slip (July 22, 2006 - Geneva State Park

Western Reserve District - United Methodist Church
EVENT PERMISSION SLIP

To Whom It May Concern:
(child's name)_________________________has my permission to go to the Western Reserve DYC Beach Party on

July 22, 2006 from 2:00 PM until 6:00 PM. It will be held at Geneva State Park on Route 534 in Geneva-On-The-Lake.

We will have Jet skis at this event. They will only be operated by adults. Youth will be allowed to ride Jets skis as

a passenger only with parental permission. Do you give your child permission to ride as a passenger on Jet Skis at this

event YES NO (circle one). We will not allow the child to ride without a parental signature.

Parental or Guardian Signature ___________________________________________________________
Relationship to Child: ____________________________

Phone number in case of emergency: Where parent(s)/guardian may be reached during the event: _____________________________
Alternate contact in case parent(s)/guardian cannot be reached:
Name_________________________________ Phone ___________________________________

Medical/Health Information
Allergies, medication, hay fever, insect bites, asthma, food, other:
______________________________________________________________________________________________________

Other pertinent health history information: _________________________________________________

____________________________________________________________________________________

Does your child/youth have any conditions that would prevent him/her from fully participating in this
program? If yes, please explain: (specific activities/foods to avoid)
____________________________________________________________________________________

____________________________________________________________________________________
List any medication to be taken during the event which will be kept by the leaders during the event:

Preferred Doctor Phone __________________________Phone __________________________
Preferred Dentist Phone __________________________Phone __________________________
Preferred Eye Doctor Phone __________________________Phone _______________________
Preferred Hospital _______________________________ Phone _________________________

EMERGENCY MEDICAL AUTHORIZATION

I give my consent for emergency medical treatment by a certified first aider. In the event that additional treatment is needed, the staff of the Emergency Room of the hospital listed above, or one closest available to the event location, has my permission to treat my child.

Event: DYC Beach Party at Geneva State Park
Date: July 22, 2006

Child's Name: _____________________________

Parent Signature: ___________________________
Date: _____________________________________

Address: ___________________________________

____________________________________

____________________________________

Phone _____________________________________

Cell Phone ___________________________________