I hereby give permission for _______________________________ to attend the Episcopal Diocese of South Carolina’s Youth Ministry Event ________________________ and participate in it’s activities. I also give permission for emergency medical treatment to be administered to my child, and for medical treatment decisions to be made by the youth leaders on this event. I understand that attempts will be made to contact me in the event of an emergency. I also hold harmless the Episcopal Diocese of South Carolina and the staff and leaders involved in this event.

Your Signature: _______________________________________ Today’s Date: __________________

Day Phone #: _______________________ Evening Phone #: ________________________

Your Name(s): __________________________________________________________________

Medical Insurance Company: _____________________________________ ID/group #: __________________