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Permission and Medical Release Form

This is the form for the Parent/Guardian to sign

Event Details

Event Details: Youth Activity - Bristol Skateway

Dates of Event: February 8, 2022

Describe event and activities (please be specific): Roller skating at the Bristol Skateway

Ward: Kingsport Ward

Stake: Kingsport Tennessee Stake

Event or Activity Leader's Email: bishop@ewi.ng

Participant Information

Participant:

Dates of Birth:

Age:

Telephone Number:

Address:

Emergency Contact:

Phone Number:

Medical Information and Physical Conditions That Limit Activity

Does the participant have any health conditions or special needs?

Description:

Does the participant have any allergies?

Description:

Does the participant require any medication during the event?

Description:

Permission

I give permission for my child or youth to participate in the event and activities listed above (unless noted) and authorize the adult leaders supervising this event to administer emergency treatment to the abovenamed participant for any accident or illness and to act in my stead in approving necessary medical care. This authorization shall cover this event and travel to and from this event.

The participant is responsible for his or her own conduct and is aware of and agrees to abide by Church standards, camp or event safety rules, and other pertinent instructions. Participants' conduct and interactions should abide by Church standards and exemplify Christlike behavior.

Parents and participants should understand that participation in an activity is not a right but a privilege that can be revoked if they behave inappropriately or if they pose a risk to themselves or others.

Parent/Guardian Signature

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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February 2, 2022 8:44 pm EST

Permission and Medical Release Form Uploaded by Kingsport Ward - hello@kptward.com IP 24.183.197.165