BETHANY COVENANT CHURCH PERMISSION SLIP Canobie Lake Park

June 26, 2012 My child, has permission to attend the event at Canobie Lake Park in Salem, NH I understand that every effort will be made to protect and safeguard all participants. Therefore, I agree not to hold Bethany Church or any of its staff and chaperones liable for any illness or mishap occurring in transport to and/or during the event. I understand that adult supervision is being provided for the event and I authorize any treatment by an accredited hospital and/or physician if it is deemed necessary for my child. I understand I will be responsible for picking up my child at any time if my child becomes unruly. Parent/Guardian signature (date) phone

DONT FORGET BACK SIDE!

Form is due Sunday June 17. Cost is $30

No refunds after June 24.

Medical Release Form

Bethany Covenant Church wants to assure you and your child that they will receive the best possible care in the event of an accident. We would like to have a copy of any medical conditions or awareness that would benefit us in treating your child either in route to or from our excursion. This form will be with Bethany counselors at all times and will be used to help treat your student should a need for treatment arise. I authorize any treatment by an accredited hospital and or physician if it is deemed necessary for my child. Parent/ Guardian Signature_______________________________________________ Students name_________________________________________________________ Chronic health problems/Allergies:__________________________________________ _____________________________________________________________________ Special medications used:________________________________________________ _____________________________________________________________________ Medical Insurance Company_________________________________ Phone Number______________________ Policy Number____________________________________ Parent or legal guardian contacted in case of an emergency:_____________________ Phone number:________________________________ I want to emphasize the importance we are placing on your childs safety and well being. In the event of an emergency we want your child to receive the best and quickest health care possible.