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
Please
Print
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 (
)
MEDICAL
QUESTIONNAIRE
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
Other
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
Generationactzyouthministries@yahoo.com