Collinsville Baptist TabernacleThis form is to be completely filled out and signed by a parent or legal guardian before a child may participate in this event.

Permission Slip

Please Print: Parent or guardian name _________________________________________________________________ Address __________________________________________________________ Apt. No. ____________ City ______________________________________________________ Zip ________________________ Home Phone __________________________________________ Alt. Phone _______________________ Please list everyone of your household who has permission to attend Collinsville Baptist Tabernacles

Double Dare - August 29, 2009 2pm-8pm Cost: $10

I paid for REFUEL, please move my refund to this eventName Relationship to you Age _______ _______ _______ Date of Birth _____________________ _____________________ _____________________ ___________________________ ________________ ___________________________ ________________ ___________________________ ________________

Do any of the above have allergic reactions to any medications? Circle one Yes If so, please list their name(s) and the medication(s) to which they are allergic:

No

_____________________________________________________________________________________ Other Information: ______________________________________________________________________ I hereby give my permission for all listed above to attend this event and participate in all activities. I understand that my child(ren) will be under adult supervision. I further understand that in signing this permission slip, I release and hold harmless Collinsville Baptist Tabernacle, its trustees, officers, employees, and any volunteers from any liability, past or future, fully and completely. I authorize the executive staff or designated medical professionals to administer emergency medical assistance if I cannot be reached. Parent or legal guardian signature _________________________________________ Date ____________