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Permission and Release Form

Event Information
Date _____________________________________________________________

Event Description _____________________________________________________________

Destination _____________________________________________________________

Departure Time/Location _____________________________________________________________

Estimated Time of Return _____________________________________________________________

Means of Transportation _____________________________________________________________

These adults will be accompanying the children for this event:

_________________________Phone #__________ _________________________Phone #__________

_________________________Phone #__________ _________________________Phone #__________

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Event Permission
As parent/guardian of ___________________________________, I understand that my child is to take
the trip described above. I give permission for my child to participate and I release Capital City Church
Assembly of God and its agents from any and all liability which may arise during or relating to the trip,
except liability for damages or injuries caused by the sole negligence of Capital City Church Assembly
of God.

____________________________________________ ______________________
Signature of Parent/Guardian Date

________________________________________________
Phone where I can be reached during the field trip

Medical Permission
Please list below any medicine to be taken or medical care that will be necessary during or
immediately prior to the event.

_________________________________________________________________________________________

_________________________________________________________________________________________

By signing below, I am authorizing emergency medical treatment during this outing for the above
named child, should it be deemed necessary by licensed medical personnel.

____________________________________________ ______________________
Signature of parent/guardian Date

Capital City Church Assembly of God, 1290 Old Henderson, Columbus, OH 43220, 614-442-1700
www.capitalcitychurch.org