Student's Name:

Address:   

Home Phone:  

Parent Work:  

Health Insurance Company:

Address:

Policy and/or Group Plan Number:

Identification Number of Insured:

Emergency Treatment Authorization Phone Number:

I am aware of the potential risks to my child and his/her property as he/she participates in

on .

(name of activity)

(Date of Activity)

With such knowledge, I voluntarily release the Presbyterian Church of America, Wellington
Presbyterian Church, and their employees and representatives from any and all liability
related to the activities of the event mentioned above.

In the event of a medical emergency and I can not be contacted, I hereby consent to the
necessary and proper treatment, surgery, and/or anesthetic by a licensed physician or
health care professional for my child. 

Name of Parents or Guardians:         Date

                                              Date

By pressing the "APPROVAL" button I am signing this Parent Permission Form electronically and I am stating that I am the parent or guardian of the said child mention above.