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DESPERATION CHURCH
Desperation Students Waiver 2023
Permission/Medical Release for:
*
First Name
Last Name
Phone
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date Of Birth
School
Grade
5
6
7
8
9
10
11
12
College
Parent/Guardian Name
First
Last
I give permission for my child to join the Student Ministry of Desperation Church in any of the activities or trips sponsored by the church, its staff and sponsors. I hereby release them from responsibility and liability for any illness or injury that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity as agent for me, to consent to any x-ray examination, medical, dental, or surgical diagnosis, treatment, and hospital care advised and supervised by a physician, surgeon, dentist (as appropriate), licensed to practice under the laws of the state where services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible.
This document will be valid and in full effect from January 1, 2023 – December 31, 2023
Parent's Signature
*
Emergency Phone 1
*
Emergency Phone 2
*
Medical Information
Allergies
Medications being taken
Physical handicaps
Medical Insurance Co
Name of policy holder
Policy #
You will not be allowed to go on any Student trip off-campus with Desperation Church without a permission slip signed by your parent/guardian on file.
If a discipline problem is deemed serious enough, the child will be sent home at the parent’s expense.
I have read and agree to follow these guidelines.
Child's Signature
Parent's Signature
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