Annual Permission Slip

Please Note: Parents are responsible for ensuring that NorthCreek Church has the most current information regarding their son or daughter.

A new Permission Slip must be filled out and placed on file if there are any changes to the following: Insurance provider, doctor, meds used, emergency contacts and phone numbers, etc.

This document will be kept on file and used in the event of a problem or emergency for your son or daughter while they attend and participate in our event/activities.

We recommend you download the following pdfPDF file or you can print this page. Hard copies are available upon request and at Flock worship on Sundays.

Please Print clearly

Student Name: ___________________________ Grade (Fall 2008): _____

Address: _____________________________
City: _________________________________ Zip: _______

Home Phone: (_____) ______________________


Parent/Guardian Name(s): __________________ , __________________

Cell phone #s: ______________________ , ______________________

(Student’s name goes here)

___________________________ has the permission of the undersigned to participate in Flock activities through July 31, 2009. In the event of an emergency affecting the heath or welfare of this participant, the sponsors, leaders, or adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the parents or guardians of the participant. Insurance afforded by NorthCreek Church of Walnut Creek is an excess insurance, over any and all valid and collectable insurance coverage available to or for such person, as expressly named above.

Initial here if you DO NOT want your student's photo to appear on the NorthCreek website.______(Student's names are NEVER published on the NorthCreek website)

Participant’s Health Insurance Carrier: __________________________________

Policy # _______________________

In the event that I/we can’t be reached…. an emergency call may be made to: __________________________ whose phone number is (____) ____-_______.


Signature of Parent or Guardian: ________________________________

Date: ___ / ___ / ___ (signature required)

Student’s Medical Update
Date of Birth: ___ / ___ / ___

Date of last Tetanus injection: ___ / ___ /___

Current Medications: ________________________________________________

Allergies: _________________________________________________________

Any Special medical instructions: ______________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

(If necessary continue on the other side)