Please print this form for completion and submission to the youth leader responsible for supervising the event.

Event: _____________________________________________

Youth's Name: ______________________________________

Address: __________________________________________

Birthdate: _________________________________________

Grade: ___________________________________________

Phone number: ____________________________________

Emergency contact and phone number:

________________________________________________________

I understand that, in the event that medical treatment is needed, every effort will be made to contact me. However, if I cannot be reached, I give my permission the director of the facility or Bethany youth leaders to secure the services of a licensed physician to provide the care necessary, including anaesthesia, for my child's well-being. I further agree that I will not hold the facility, the Presbytery of Seattle, Bethany Presbyterian Church, their agents or employees responsible for any accident or injury.

Signed: ___________________________________________

Date: _____________________________________________