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 # _____________________