Medical Authorization and Parental Permission Form

Dear Parents/Guardians,


Our church will be traveling for our Summer Retreat. In this retreat, your child will be doing several activities as well as enjoying his/her time swimming, running, praying together, and being together.  Also, we have included in this form for your information the cost of what your child must pay for him/her to join this Summer Retreat. 


I hereby request and authorize the church youth groups leaders and/agents, hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child. This authorization includes the authority to consent to any x-ray examinations, anesthetic, medical procedure or treatment, and hospital care under the supervision, and upon the advice of or to be rendered by, a physician or surgeon licensed under the existing laws.

TAKE NOTE: As much as possible, kindly provide authorization of both parents or guardians of the child who wishes to participate in the Summer Retreat.



I hereby release the church and its leaders, agents, and other officers the responsibility of any liability involving injury or accident causing circumstances and will accept full responsibility for my child’s actions.


Participant’s Name:  %child_first_name% %child_last_name%

Event Name: 

Event Coordinator: 


Time of Departure:

Destination Address:

Total Cost:

Mode of Transportation:


I PERMIT my child to attend the Church Summer Retreat.
I DO NOT PERMIT my child to attend the Church Summer Retreat.