BETHANY COVENANT CHURCH

PERMISSION SLIP

Climbing Day at Vertical Dreams

April 9, 2011

My child, has permission to attend the event at

Vertical Dream Rock Climbing Gym sponsored by Bethany Covenant
Church and Moose River Outpost.

I understand that every effort will be made to protect and safeguard all
participants. Therefore, I agree not to hold Bethany Church, Moose River
Outpost or any of their respective staff and chaperones liable for any illness
or mishap occurring in transport to and/or during the event. I understand
that adult supervision is being provided for the event and I authorize any
treatment by an accredited hospital and/or physician if it is deemed
necessary for my child. I understand I will be responsible for picking up my
child at any time if my child becomes unruly.

Parent/Guardian signature (date) phone

This is your ticket into the event. Please bring it with you to Vertical
Dream.

Don’t forget page 2!

Medical Release Form

Bethany Covenant Church and Moose River Outpost want to assure you and your child
that they will receive the best possible care in the event of an accident. We would like
to have a copy of any medical conditions or awareness’ that would benefit us in treating
your child either in route to or from our excursion. This form will be with Bethany
counselors at all times and will be used to help treat your student should a need for
treatment arise.

I authorize any treatment by an accredited hospital and or physician if it is deemed

necessary for my child.

Parent/ Guardian Signature_______________________________________________

Student’s name_________________________________________________________

Chronic health problems/Allergies:__________________________________________

_____________________________________________________________________

Special medications used:________________________________________________

_____________________________________________________________________

Medical Insurance Company_________________________________

Phone Number______________________

Policy Number____________________________________

Parent or legal guardian contacted in case of an emergency:_____________________

Phone number:________________________________

I want to emphasize the importance we are placing on your child’s safety and well
being. In the event of an emergency we want your child to receive the best and
quickest health care possible.