TRINITY COVENANT CHURCH
5020 Liberty Road South Salem , OR 97306 [503] 581-5675

PERMISSION SLIP FOR:

Name:   Telephone #: :

Address   Zip Code:

TO TRAVEL WITH TRINITY COVENANT CHURCH:

Date:   To/From:

In the event of an emergency, I give Trinity Covenant Church permission to act on my behalf in seeking emergency treatment for my child if deemed necessary. I give permission to those administering emergency treatment to do so. I absolve Trinity Covenant Church from liability in acting on my behalf in this regard so long as Trinity Covenant Church is not grossly negligent.

Signature: _______________________________________________________Date:
                     [parent/guardian]

Insurance Carrier:       Policy Number:

PLEASE RETURN THIS FORM TO THE CHURCH OFFICE