Health Concerns____________________________________________________________
Special Needs/Restrictions____________________________________________________
Physician ________________________________ Phone___________________________

         My son/daughter, named above, has my permission to attend the event/activity named above, with the youth group of First Christian Church (Disciples of Christ) in Burlington, IA. I understand that the youth and their adult sponsors will be traveling out of town.
         In the event of illness or accident, if the parent or guardian cannot be reached, I authorize the church, or its agents, to consent to any diagnosis, examination, treatment, or hospital care for my child which is deemed advisable by, and is rendered under the supervision of a physician. I release the church and its agents from responsibility in the case of an accident or illness in connection with this event.

Signature of Parent/Guardian__________________________________________________
Date___________________________