Youth Permission Slip

Permission is granted for the Event: Heart Conference Overnight Sleepover
Date: February 22 - 23rd
*Parent/Guardian's first and last name:
*Parent/Guardian's cell phone number:
*Parent/Guardian's email address:
*Student's first and last name:
*Students cell phone number:
*Does student have any special physical problems of which we should be aware?:
*Is student currently taking any medications, if so, please list:
By signing this form I give my child permission to participate in the above-mentioned event. In the event that he or she is injured while participating, I do hereby authorize and consent  to any x-ray, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member under the provisions of the Medicine Practice Act. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable. It is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached. I also agree to accept all responsibility for the cost of the above-mentioned medical services. I understand the nature of this event and do hereby release Pure Heart Church, or any of its representatives from any liability for accidents or injury sustained by my child in conjunction with this event. 
*Parent/Guardian Signature (Full name):
*Date signed: