The Lighthouse Co-op
CONSENT AND RELEASE FROM LIABILITY
and Standard Permission Slip
Camano Chapel, Camano Island, Washington
Student Name: ______________________________
Date of Birth: ________________________
Parents' Names:______________________________
Phone No.: __________________________
Emergency Contact: __________________________
Phone No.: __________________________
Insurance Provider: ___________________________
Policy No.:__________________________
Any known allergies? _________________________
Medications: ________________________
I,______________ the parent of ________________, do hereby consent to
his/her participation in the following Lighthouse Co-op class activities:
Trip Destination: __________________________________
Date of Trip: _________________
Trip Destination: __________________________________
Date of Trip: _________________
Trip Destination: __________________________________
Date of Trip: _________________
Trip Destination: __________________________________
Date of Trip: _________________
I authorize the leaders of the above activities to obtain emergency care and treatment deemed necessary.
I DO HEREBY AUTHORIZE AND HOLD HARMLESS CAMANO CHAPEL, and all of its ministries and departments, each of the leaders and each of the accompanying persons FROM ALL LIABILITY for mishap or injury of any nature whatsoever.
Signature of Parent: _______________________________________
DATED this _________ day of ____________________, 20________