2017 Six Flags Permission Slip PDF

October 21, 2017
8:30 AM 11:30 PM
$50 before September 27
$60 after September 27
$15 with Season Pass
Wacky Olympics black team goes for FREE!
Bring money ($25 or so) for lunch and dinner.
Turn money in to Pastor Quentin or his assistant in the Church Office.
Make checks payable to Calvary Church.
Permission Slip
(Please return with payment and medical consent form by September 27, 2017)
I _________________________________________ (Parent/Legal Guardian) give permission
for my child(ren) _________________________________________ to attend the Revolution
outing to Six Flags St. Louis on October 21, 2017, under the guidance and supervision of
its representatives. In case of emergency during this event, I can be reached at
_________________________ ____________________________
Phone Number Cell Phone Number
________________________________________________
Signature of Parent/Guardian
SCHEDULE
8:30 AM Meet at Calvary (Jefferson Campus)
9:00 AM Bus leaves for St. Louis
11:00 AM Lunch at McDonalds
12:00 PM Arrive at Six Flags
9:00 PM Head back to Springfield
11:30 PM Parent pick-up (Jefferson Campus)
Calvary Church
Medical Consent
____________________________________ (Name of Child) has my permission to participate in all sponsored activities with,
Calvary Church, Springfield, Illinois. My child is in good health and is able to participate in all normal church activities. I HAVE
READ THE TERMS STATED AND THE RULES GOVERNING MY CHILDS ACTIVITIES AND ON THIS APPLICATION
AGREE THERETO.
NOTE
While your child is in the care of the leaders of Calvary Church, an emergency, illness, or accident may occur which requires
immediate medical or dental attention. In Civil Code, 410ILCS210/3, the Illinois Legislature has authorized consent in advance by
parent or guardian for such treatment. Such consent serves to protect Calvary Church, the leader(s), the doctor(s), and you by
assuring that prompt emergency treatment can be administered.
This form enables you to provide this consent as well as to offer information helpful in the treatment of your child. Before all major
church-sponsored activities in which your child participates, you will receive notice advising you of the activity, mode of
transportation, and leaders involved and enabling you to reaffirm your consent.
CONSENT TO TREATMENT OF A MINOR

The undersigned parent(s) or guardian of the child named _________________________________, a minor, hereby authorizes
Calvary Church, the leader(s), or such substitute as he or she may designate as agent for the undersigned, to consent to any x-ray
examination, anesthetic, medical or dental diagnosis or treatment, and/or hospital care to be rendered to said minor by a licensed
physician, surgeon or dentist, whether such diagnosis or treatment is rendered at the office of said physician or dentist, in the
hospital, or otherwise.
This authorization is given prior to any diagnosis or treatment known to be required in order to enable said leader(s) or agent(s) to act
effectively in an emergency situation where I cannot be contacted. Should said leader(s) or agent(s) exercise their authorized consent
hereunder, upon the advice of a licensed physician, surgeon, I KNOWINGLY AND VOLUNTARILY EXONERATE AND
RELEASE SAID LEADER(S), AGENT(S), AND CALVARY CHURCH, FROM ANY LIABILITY FOR THIS ACTION.
The undersigned parent(s) or guardian of the child named _________________________________, a minor, hereby takes full
financial responsibility for any accident or injury to said child, and releases Calvary Church, the leader(s), or such substitute of any
financial responsibility for any accident or injury that may occur while in their care.
I understand that all reasonable measures will be taken to safeguard the health and safety of my child and that I will be notified as
soon as possible in case of an emergency.
This authorization shall remain effective for a period of one year beginning October 1, 2017, or until revoked in writing by Calvary
Church, Springfield, Illinois.
_______________________________________________
SIGNATURE OF PARENT OR LEGAL GUARDIAN
_______________________________________________
ADDRESS
_______________________________________________
PHONE
INSURANCE CARRIER POLICY NUMBER

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October 21, 2017

CONSENT TO TREATMENT OF A MINOR

INSURANCE CARRIER POLICY NUMBER

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