FAMILY PRAISE FELLOWSHIP

3669 Madison Street, Riverside, CA 92504

(951) 689-3031

As parent or legal guardian of (Child’s Name) ____________________________, I give my permission for him/her to attend the following:

Date of Event: ___________________________________

Event Name: ____________________________________

Location:  _______________________________________

Time of Event: ________________ to  ________________

I do hereby release Family Praise Fellowship in case of loss of personal goods or bodily injury and authorize the leaders of this group to take the above named child to a doctor or hospital for treatment in case of emergency. I understand I will be notified immediately of any emergency related to my child.

Address:  ________________________________    Home Phone: ______________________________

                 _______________________________    Cell Phone:________________________________

                 _______________________________    Alternate Contact Name: _____________________

                 _______________________________    Alternate Contact Number:____________________

Print Name of Parent/Guardian: ____________________________ Relationship to child: _____________

Signature of Parent/Guardian:  __________________________________ Date: ____________________

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To the Doctor:

This is to authorize you to treat the above named child in case of emergency requiring a doctor’s care.

Signature of Parent/Guardian: __________________________________ Date: ____________________

Date of last Tetanus Shot: ______________________  Allergies: ________________________________

Other: _______________________________________________________________________________