Student Name: _____________________________________________________________
Address: _____________________________________ Birth date: ____________________
City, State, Zip: _____________________________________________________________
Home Phone (                  ) ________________________

Sex:    M    F       Grade: (as of Fall 2005) ___________

Medical Considerations/Allergies: _______________________________________________
Emergency Day Number:                                     Emergency Night Number: _______________
Emergency Contact Person: ____________________________________________________

I hereby give my permission for my child to participate in all activities organized by First Presbyterian Church of Georgetown, Texas. My child has my permission to travel by vehicle to and from any trips and/or special events and I understand that all vehicles will be driven by licensed adults from First Presbyterian Church. Youth will not be allowed to drive personal vehicles unless specially detailed in trip information sheets and unless permission has been granted in writing by myself and the adult leader of the event or trip.

Authorization for Consent to Treat a Minor

In the event of illness or accident and in my absence, I authorize the adult leaders and/or sponsors 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. In situations where professional medical care is not immediately available or is deemed unnecessary by adult leaders, I authorize the adult leaders to administer first aid treatment to my child.

I hereby release First Presbyterian Church and its agents from responsibility in the event of an accident or illness on connection with any authorized church activities.

The above authorizations will remain in effect from May 30, 2005 or the date below until June 1, 2006, for all trips or special events sponsored by First Presbyterian Church of Georgetown, Texas unless revoked in writing by the undersigned, and delivered to the Youth Director of First Presbyterian Church.

Signature of Parent or Guardian: __________________________________________________

Relationship to Minor:                                               Date: ______________________________