2007-08 Rock Annual Permission Slip

This document will be kept on file and used in the event of an emergency or situation for your son or daughter while they attend and participate in our event/activities.
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 on file if there are any changes to the following: Insurance provider, doctor, medications used, emergency contacts, and phone numbers, etc.


Student Name: _________________________________ Grade: _____

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 Rock activities for July 1, 2007 to June 30, 2008. In the event of an emergency affecting the heath or welfare of this participant, the sponsors, leaders, or other 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.

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)