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St. John’s Youth Permission Form


NAME:__________________________________________

Date of birth:_____________________________________


Parent/Guardian information:

Name:______________________________________________________________

Home telephone number:_______________________________________________

Business telephone number:_____________________________________________


Medical Information

Does the participant have any of the following:

__ Special diet   __ Allergies   __ Medication   __ Chronic/Recurring illness

__ Surgery or a serious illness in the past year   __ Physical conditions that limit activity

If yes, explain:_______________________________________________________

Medications:________________________________________________________


Parental/Guardian Permission

I give permission for my child/youth to participate in the activity and authorize the adult leaders supervising this activity to administer emergency treatment to the above-named participant 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 this activity.


Parent/Guardian signature:____________________________________________

Date:_____________________________________________________________