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: Handy Dirty Service

March 15, 2011 10am - 4pm
Location: around Collinsville
Cost: lunch money ** wear work clothes

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: Yes No
If 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 all
activities. 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 Collinsville
Baptist 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 give
my 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_ _______