| Signature of parent/guardian: _______________________Date________ |
| I give permission for my youth to participate in the activity listed above and authorize the adult leaders supervising |
| this activity to administer emergency treatment for any accident or illness and to act in my stead in approving |
| necessary medical care. This authorization shall cover this activity and travel to and from the activity. |
| Activity: |
| Birthday: |
| Comment: |
| Parental or Guardian Permission and Medical Release |
| Dates: |
| Name: |