The Refuge Youth Ministry The Refuge Youth Ministry Corn Maze Permission Slip Medical Release Form/Permission Slip Students Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY I give permission for the above named child to join the Refuge Youth Ministry of Abundant Life Fellowship, Butte, Montana to attend the Montana Corn Maze located in Manhattan, Montana. I understand that the group will be traveling via bus which is being provided by Journey Church of Butte, Montana. I hereby release Abundant Life Fellowship, its staff and sponsors, from responsibility and liability for any injury or illness that my child may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to consent to any X-ray examination; medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible. Signature of natural parent or legal guardian * Date Signed * MM DD YYYY By checking this box I confirm my permission as outlined above. * I agree Emergency Phone Number * (###) ### #### Email * Parent/Guardian Email MEDICAL INFORMATION Allergies * Medications being taken * Physical handicaps or limitations * Medical insurance company * Policy Number * Member's name * Thank you!