Name ___________________________ Age __________ Birth date ________________

Address ________________________________________ Phone (____)_____________

City ____________________________ State _____________ Zip Code _____________

School _______________________________Grade in or just completed _____________

Parent(s) business phones          ____________________________________

                                                ____________________________________

 To Whom It May Concern:

The undersigned does hereby give permission for our (my) child, ___________________

______________________________________, to attend and participate in activities

                        (Name of Child)

sponsored by Lighthouse Youth & First Presbyterian Church on ____________________

                                                                                                                        (Date)

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of the licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

            The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental service rendered to the aforementioned child pursuant to this authorization.

            Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

            The undersigned does also herby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by the Lighthouse Youth & First Presbyterian Church.

            The undersigned does also herby give permission to photograph and video tape our (my) child, and to use these photographs and videos to promote Lighthouse Youth in marketing tools such as but not secluded to bulletin boards, brochures, flyers, videos, and website.

Hospital Insurance       Yes     No                      ____________________________________

                                    (Circle One)                  Participant                                            Date

Insurance Company _________________        ____________________________________

                                                                        Father                                                   Date

Policy Number _____________________

                                                                        ____________________________________

Emergency Phone Numbers                               Mother                                                 Date

_________________________________

                                                                        ____________________________________

_________________________________      Legal Guardian                                      Date

**On the reverse side of this page, please list any allergies or special medical problems your child may have.   Thank you.