The Worms of Baptist Tabernacle

This form is to be completely filled out and signed by a parent or legal guardian before a student may participate in this event.

The Event:

Guy’s Night

Tuesday, October 18-19, 2011 @ 9pm-9amLocation: Collinsville & Owasso (various)Cost: $10 + breakfast @ IHOP $ (eat dinner first)

Student’s Name ___________________________________ Birthday ___/ ____ / ___ Current School Attended ______________________ Age_______ Grade_________ Physical Address __________________________ _________________ Apt. No. _____ Mailing Address

(if different than above)

___________________________________________ City ________________________________________ Zip ________________________ Home Phone ________________________ Cell Phone _________________________ Parents’ Name(s)__________________________________________________________ Parents’ Cell Phone _______________________________________________________ Do any of the above have allergic reactions to any medications? Circle one: YesNoIf so, please list their name(s) and the medication(s) to which they are allergic: __________________________________________________ I hereby give my permission for all listed above to attend this event and participate in allactivities. I understand that my child(ren) will be under adult supervision. I further understand that in signing this permission slip, I release and hold harmless CollinsvilleBaptist Tabernacle, its trustees, officers, employees, and any volunteers from any liability, past or future, fully and completely. I authorize the executive staff or designated medical professionals to administer emergency medical assistance if I cannot be reached. I givemy permission for my child(ren) to be admitted to the emergency room of a hospital for treatment by the hospital staff if needed and at the discretion on the assistant pastor or youth volunteer.Parent or legal guardian signature _______________________________ Date_ _______