Trip To Duluth!

Friday, January 20th

6:00pm to 11pm
(Meet at the Virginia Teen Center)

----------------------------------------------------------------------------------------------------------Students Name: ________________________________ Cell

Phone:_____________________
Address: _________________________ City/ State _________________________ Zip:
______
Age:_______ Grade:_______ School:_______________________________________________

Permission and Release Form

I, the undersigned, have legal custody of the student named above and have given consent
for him/her to attend events organized by Mesabi Range Youth For Christ Ministries. I
understand that there are inherent risks involved in any ministry or athletic event, and I
herby release the YFC Organization, its staff, and volunteer workers from all liability for any
injury or illness that may occur during the course of my childs involvement. In the event of
an emergency, I hereby authorize an adult leader of this activity, to act as an agent for me,
to consent to any x-ray, examination, treatment and hospital care advised by a licensed
physician. I expect to be contacted as soon as possible.

Parent/Legal Guardians Signature:

______________________________________Date:___________
Emergency Phone Numbers:
Phone 1:____________________________ Phone 2:__________________________________
[Cell or Home]
[Cell or Home]
Medical Information:
Allergies:___________________________________________________________________________
_

Present
Medications:__________________________________________________________________
Physical handicaps or limitations:
_______________________________________________________
Medical Insurance Company: _______________________________ Policy #
_____________________