Koza Baptist Church
Student Permission Form

Please provide the following information:

Name (Full Name):
Sex:		(Select Student's Sex) Male Female
Date of Birth
Home Phone:
Parents' Names
Parents' Email:
If Parents are not available in the event of an emergency, notify:
Name:
Relationship:
Phone:
Address:
Health Insurance Company:
Policy #:
Insurance Company Phone #:
Please list any current or previous health conditions or allergies that leadership should be aware of:
Please list any medications that the participant is currently taking, including does and schedule:
(Select the appropriate choice) My child has permission to participate My child does not have permission to participate		PARENTAL AUTHORIZATION - MUST BE SIGNED BY PARENT OR GUARDIAN IF PARTICIPANT IS UNDER 18. My child has permission to take part in all retreat activities under supervision and I agree Koza Baptist Church will not be held responsible for accidents or personal injury arising therefrom. In the case of medical emergency, I understand that every effort will be made to contact the parents or guardians of the participant. In the event I cannot be reached, I hereby give permission to the medical examiner selected by the Koza Baptist Staff and/or Adult Leaders to hospitalize, to secure proper treatment for, to order injection, anesthesia, or surgery for my child as named on this form.
(Select the appropriate choice) I agree to pick up my child immediately upon request I do not agree to pick up my child immediately upon request		In the event of behavioral problems, I agree to pick up my child immediately upon request.