VAN TRANSPORTATION PERMISSION FORM
Child(ren)’s Name(s) Phone ( )
I (Parent’s Name) give my permission for an insured, authorized driver from Generation Actz to pick up and drop off my child(ren) for a youth retreat which will be held at Sleepy Hollows Campground in Catawba Island, Ohio. I understand that he/she/they will be picked up between Friday morning and will be dropped off Sunday evening. I understand that exceptions may be made with a later drop-off time if there are extenuating circumstances, a lack of drivers available or extra children that need to be dropped off before my child(ren). In such a case, all attempts to reach me via my cell or home phone will be made. I understand that my child(ren) will not be able to ride the van without this form being filled out. I understand that the van is offering rides to children age 11 and above. Anyone under age 11 cannot ride the van unless accompanied by a parent, unless they are a relative of the Directors or a child of a board member. Furthermore, I also understand that if my child(ren) board the van against my knowledge when they are grounded, etc., that Generation Actz will not be able to turn the van around to bring my child(ren) home. I understand that if there are any changes to my child(ren)’s attendance, I need to contact Generation Actz ahead of time. In that situation, I would need to come and get them myself, or wait until the event is over for them to arrive home via the van. Also, the van and its drivers and all passengers are insured with a Progressive commercial insurance policy, complete with roadside assistance.
This permission slip is good from now on, so you will not have to fill out another one
once it is on file with the Directors.
Date Parents Signature
Home Phone Cell Phone
MEDICAL RELEASE FORM
Child’s Name Date of Birth Age Grade Sex
Father’s Name Mother’s Name
Address City State Zip
Home Phone ( ) Cell Phone ( )
Family Doctor Dr. Phone ( )
Is/are your child(ren) presently being treated an injury or sickness or taking any form of medication for any reason? Yes No (If yes, please explain)
Does your child require a special diet? ? Yes No (If yes, please explain)
Does your child have (or has ever had) any of the following (circle, and explain below)
Seizure Disorders Asthma Heart Murmur Diabetes Kidney Disease
I, the undersigned, being the parent or legal guardian of the child(ren) named above, do hereby consent to the participation of my child(ren) in all the regularly scheduled activities of Generation Actz. Further, I certify that my child is physically fit and adequately trained to participate in such events.
I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that Generation Actz will not be responsible for medical expenses incurred solely on the basis of this authorization.
Signature of Parent/Guardian Date
Generation Actz, John & Tonya Berry, 1678 Huxley Drive, Columbus, OH 43227, Home (614) 626-4644 Cell (614) 668-0607