Desperation Students 2023 Waiver - Desperation Students

Permission/Medical Release for:*

First Name Last Name

Phone

Address*

Street Address Address Line 2 City State ZIP Code

Date Of Birth

School

Grade

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

Desperation Students Waiver 2023