Collinsville Baptist Tabernacle Permission Slip

This form is to be completely filled out and signed by a parent

or legal guardian before a child may participate in this event.

Please Print:
Parent or guardian name _________________________________________________________________

Address __________________________________________________________ Apt. No. ____________

City ______________________________________________________ Zip ________________________

Home Phone __________________________________________ Alt. Phone _______________________

Please list everyone of your household who has permission to attend Collinsville Baptist Tabernacle’s

Frontier City – July 13, 2009 @ 8am-11pm - $20 + food

** Note: Shorts must come to the knee, no tank-tops, any shoes fine – wear a Worms shirt if possible

Name Relationship to you Age Date of Birth

___________________________ ________________ _______ _____________________

___________________________ ________________ _______ _____________________

___________________________ ________________ _______ _____________________

Do any of the above have allergic reactions to any medications? Circle one Yes No
If so, please list their name(s) and the medication(s) to which they are allergic:

_____________________________________________________________________________________

Other Information: ______________________________________________________________________

_____________________________________________________________________________________

I hereby give my permission for all listed above to attend this event and participate in all activities. I
understand that my child(ren) will be under adult supervision. I further understand that in signing this
permission slip, I release and hold harmless Collinsville Baptist Tabernacle, its trustees, officers,
employees, and any volunteers from any liability, past or future, fully and completely. I authorize the
executive staff or designated medical professionals to administer emergency medical assistance if I cannot
be reached.

Parent or legal guardian signature _________________________________________ Date ____________