Participant’s Name __________________________________________________________ Nickname ______________________________________
Male ___ Female ___ Date of Birth _____________ Grade ________ School _____________________________________________________
Home Address _________________________________________________________________ City ___________________________________________
Zip ______________ Parent/Guardian Email ____________________________________________________________ T-Shirt Sz. ___________
Parent/ Guardian Name (s) ____________________________________________________________________________________________________
Parent/ Guardian Home Phone _________________________________ Parent/Guardian Cell Phone _____________________________
Emergency Contact _________________________________________ Emergency Contact Phone ____________________________________
Insurance Company _______________________________________ Insurance Company Phone _____________________________________
Policy # ___________________________________________________ Group # ____________________________________________________________
Allergies or Special Needs ______________________________________________________________________________________________________
Are there any over the counter medications that the participant should not receive if any minor symptoms develop?
____________________________________________________________________________________________________________________________________
Note: Prescribed medications must be in original pharmacy container with the correct name, date,
instructions and physicians name on label. Over the counter medications must be in original container and
have dosage information clearly printed on container. The event leader will keep and distribute all
medications during the event.
My Child, __________________________________________, has my permission to attend and participate in activities sponsored
by the Episcopal Diocese of Texas and/or Trinity Episcopal Church. I represent that my child is healthy and capable
of participating without causing risk of danger, illness or accident to him/herself, or to others. I agree to hold
harmless the leaders of my church, the leaders of other churches involved, the event coordinators, ministry leaders,
the Bishop of Texas, and the Diocese of Texas in the event of any accident or injury.
In the event that my child requires medical attention while attending a meeting or event, I understand that an adult
sponsor of the event will make every reasonable attempt to contact me. In the event that I cannot be contacted, I
consent to any medical attention deemed appropriate. In the event that treatment is called for, which the medical
provider refuses to administer without consent, I hereby authorize an adult sponsor to give such consent for me if I
cannot be contacted immediately or, because of an emergency, there is no time or opportunity to make contact. In
the event that it is necessary for that person to give consent, I agree to hold such person free and harmless of any
liability for damages arising from giving such consent. I declare that my child is covered by medical insurance and/or
that I am responsible for any and all expenses incurred by my child whether covered under insurance or not.
As parent/legal guardian, I understand that promotional pictures and videos (individual and group) may be taken
during activities sponsored by Trinity Episcopal Church. I give permission for my son’s/daughter’s picture to be
used for promotional materials (newsletter, web page, calendars, power point, video, social media, etc.) in
highlighting events.
Custodial Parent or Legal Guardian Signature ____________________________________________________ Date _____________________
Relationship to Participant _______________________________________________________
Date _________________
Permission good for one year
from this date.
Updated 8/03/18