WPC  r@i ͋Z>4[qC&͸Ѳ _ݗlxw{5L$\tZ KU^;Nn1IIi>t|T[Ips%c<8UjV$e!$^*wՁpoςX_>KDrL6ڡҭ\xjsxvİrPG|mc(j?#s%}-^ =c k҄=CXY>p?'e:[P>8˘1tanodA0|/s?y "BhA}ҋLDM![2 zW=q~;˘G~o_k#!U@ %; 0(A UNi w: 4   m N- ^ / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / D3; Bn n n n n n D3 B D3 B D3+ B^ D3{ B D/ D3 B*- D3W B* HP LaserJet 5P,,,,,,0+@h*Z(Charter BT Roman($'   Z6Times New Roman Regular Eabab#"%:i+003|xU5B%XXXX'dxd d____'dxd  daaaa'dxdP Pdcccc'dxd deeee'dxd daa' dxdhhhh'dxd&0 d djjjj'dxd&P d d !  _XX1XX1   5g55XXParentalConsentandMedicalAuthorization#XX5#  Q @rvQQQQ!@  ParentsandlegalguardiansofminorchildrenareaskedtocompletethisformandreturnittoChristOurShepherdLutheranChurch.Theinformationrequestedisdesignedtoassistthechurchinprovidingforthesafetyofminorsduringchurchsponsoredactivities. GeneralInformation:  R  ChildsName______________________________DateofBirth________________________FathersName_______________________MothersName_____________________________ChildsAddress________________________________________________________________HomePhone#___________________ParentsWorkPhone#_________________ ConsentandCertification:  J I,theundersignedbeingtheparentorlegalguardianofthechildnamedabove( thechild),doherebyconsenttotheparticipationofmychildintheactivitieswhichmayincluderetreats,ropescourses,tripsoutofPeachtreeCity,poolparties,skating,andotheractivitiesthatmaybeassociatedwithyouthgroupsspecificallyatChristOurShepherdLutheranChurchofPeachtreeCity,GA.IdoNOTauthorizemychildtoparticipateinanyofthefollowingactivities:____________________________________________________________________________________________________________________________________________________________________________ Medical: Z  *Isyourchildpresentlybeingtreatedforaninjuryorsicknessortakinganyformofmedication F foranyreason?Yes______No______(Ifyes,pleaseexplain)_______________________________________________________________________________________________________*Isyourchildallergictoanytypeofmedication?Yes_____No______(Ifyes,pleaseexplain)____________________________________________________________________________________________________________________________________________________*Doesyourchildrequireaspecialdiet?Yes_____No______(Ifyes,pleaseexplain)____________________________________________________________________________________________________________________________________________________________*Doesyourchildhave(orhass/heeverhad)anyofthefollowing:(Checkandexplainbelow)_____Seizuredisorders_____Asthma______Heartmurmur______Diabetes_____Hayfever_____KidneyDisease____________________________________________________________________________________________________________________________________________________________ .F*- _ԇDoesyourchildhaveanyallergiesotherthanmedicinal?Yes______No______(Ifyes,pleaseexplain)_________________________________________________________________*Doesyourchildeversleepwalk?Yes______No______*Canyourchildswim?Yes______No______*Doesyourchildhaveanyphysicalhandicaporillnesswhichwouldpreventhim/herfromparticipatinginnormalrigorousactivity?Yes______No______(Ifyes,pleaseexplain)______________________________________________________________________________ MedicalTreatmentAuthorization: P   IunderstandthatIwillbenotifiedincaseofamedicalemergencyinvolvingmychild.However, 0  intheeventthatIcannotbereached,Iauthorizethecallingofadoctorandtheprovidingofnecessarymedicalservicesintheeventmychildisinjuredorbecomesill.Iunderstandthatthechurchwillnotberesponsibleformedicalexpensesincurred,butthatsuchexpenseswillbemyresponsibilityasparent/guardian.Iagreetonotifythechurchintheeventofanyhealthchangeswhichwouldrestrictmychildsparticipationinanynormalyouthorchildrensactivities.Ialsounderstandthattheadultsupervisorsreservetherighttorestrictmychildfromanyactivitiesthattheydonotfeeliswithinthephysicalcapabilitiesofmychild._________________________________________Date__________________Signatureofparent/guardiant