PARENTAL  CONSENT  FORM

Date must update every September
NAME AGE BIRTHDATE
ADDRESS
CITY STATE ZIP  CODE
TELEPHONE GRADE IN OR COMPLETED
PARENT(S)  BUSINESS TELEPHONE NUMBERS:  Dad Mom
CELL PHONE NUMBERS or

PARENTAL CONSENT:
The undersigned does hereby give permission for my child, to attend and participate in the youth activities sponsored by Immanuel United Methodist Church in Ripon, Wisconsin.
 As parent or guardian, I authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or hospital care.
 The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.  Should it be necessary for my child to return home due to medical or disciplinary reasons, the undersigned shall assume all transportation costs.
 The undersigned does also hereby give permission for my child to ride in any vehicle designated by the Immanuel United Methodist Church while attending and participating in activities sponsored by the Immanuel United Methodist Church Youth Group in Ripon, Wisconsin.

Student’s Signature   _____________________________________________ (signature)

Parent or Guardian   _____________________________________________ (please print)

____________________________________________________ (signature)

PARENT AND STUDENT AGREEMENT:
 We (parent and youth) understand that inappropriate behavior towards another group member, private party, church property, vehicles, the property or persons or churches we may visit during an event may result in the youth being financially liable for their actions.  In the event of property damage, the student and parent agree to reimburse all damages caused by the student.

Student’s Signature   _____________________________________________ (signature)

Parent or Guardian  ____________________________________________________ (signature)