Permission & Release Form

Family Praise Fellowship   

3669 Madison Street,  Riverside, CA 92504  (951) 689-3031

I (Mr./ Mrs./Ms.)   ____________________________________   give my permission for   ________________________

to attend  _______________________________________  at _____________________________________________ on

__________________________   from ______________  to __________________.

I do hereby release the church in case of loss of personal goods or bodily injury and do authorized the leaders of this group

 to take the above named youth to a doctor or hospital for treatment in case of an emergency.

Date___________________   Signature  _____________________________________

Relationship to Child_______________________________________

*************************************************************************************************************

Address______________________________________________________________________________________________

City_________________________________ State_______  Zip__________________

Phone__________________________   Pager/Cell_____________________________

*Emergency Phone_______________________________________________________

To the Doctor

This is to authorize you to treat  _____________________________________________________________

In case of an emergency, requiring a doctor's care.  Parents or Guardians will be notified immediately of any emergency.

Parent Signature________________________________________________________

Date of Last Tetanus Shot_______________________ Allergies___________________________________________________

Other_________________________________________________________________________________________________