Bethel Chapel - The Fire Place Youth Program

Name                                                                             Age                Birth Date    ______

Address                                                                                               Phone #                     

City                                                                             Prov.              P.C.                            

Parent(s) Business Phones                                                                                               

To The Fire Place Youth Program:

The undersigned does hereby give permission for our (my) child,                                                                              , to attend and participate in activities sponsored by Bethel Chapel from September 12, 2003 to July 1, 2004

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any medical attention to be rendered to the minor under the general or special supervision and on the advice of any physician by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. 

Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Bethel Chapel. 

Emergency Phone #                                                            Medical#                                           

Any allergic reactions?                                                                                                      

Participant signature and date                                                                                        

Father/legal guardian signature and date                                                                            

Mother/legal guardian signature and date                            

PLEASE PRINT PAGE AND CUT CONSENT FORM OUT ... THANK YOU!