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Minor Permission Slip

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I/We hereby give my/our permission for my minor child to participate in any Calvary Chapel South Bay, Inc. ("CCSB" or the "Church," used interchangeably) sponsored of organized youth activity and/or event ("Event"), which permission is given for any such Event occurring from the date this Permission Slip is signed until such minor child reaches the age of majority (i.e. 18 years old) or CCSB is notified via email or in any other form of writing that this authorization is terminated ("Term").

I/We understand that there will be adult supervision at the Event. I/We also understand that if there are any disciplinary problems with the above-named minor, it will be our responsibility to pick up our child at the site of the Event and that minor will not be eligible for future CCSB organized and/or sponsored events and/or activities without the specific approval of Calvary Chapel South Bay leadership. I/We give CCSB, a nonprofit, religious organization permission to use photography of this minor publicly. I/We understand that the images may be used occasionally in print publications, online publications, presentations, websites, and social media. I/We also understand that no monetary compensation shall become payable by reason of such use.


I/We the parent(s)/ guardian(s) of the minor named below on this authorization and consent form, do hereby authorize Calvary Chapel South Bay, Inc. as agents for the undersigned to consent to any emergency x-ray, examinations, anesthetic, medical, or surgical diagnosis, or the Medical Practice Act on the medical staff or licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this consent and authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given in advance to provide authority and power in the part of aforesaid agents/guardians/parents. This authorization and consent is given pursuant to the provisions of Section 25.8 of the Civil Code of California. The expense of any such treatments and delivery of medical services is agreed to be the sole obligation of the undersigned and not that of Calvary Chapel South Bay, Inc. Calvary Chapel South Bay, Inc. is hereby released from responsibility to pay for such services and treatments rendered.


I, the Parent and/or Legal Guardian of the above named minor living at:


HEALTH HISTORY: To protect your minor child from possible embarrassment, but not to exclude him/her from the Event and any activities associated with the Event, the following is requested. Check and give approximate dates if possible:

1. To your knowledge, has your minor child been exposed to any communicable diseases within the past 21 days?
2. Do you know of any health factors that make it advisable for your minor child to follow a limited work program of physical activity?

3. Please provide us the name and phone number of your child’s regular physician

Phone Number
Medical Insurance
Insurance Number

4. Please list any medications that your child will need to have while at the camp or event:

Any medication (including prescriptions) to be administered during your minor’s time attending the Event usually will be administered by his/her Group Director or designated representative. All medication should be clearly labeled with all pertinent information, including minor child’s FULL name, dosage AND when medication is administered, etc., and given to the Group Director when your child arrives for the Event.

**In the event of a minor illness or injury (such as cold, headache, scrapes, sprains, abrasions, and/or small cuts), I do authorize the Event Director, R.N. or EMT to give my minor child common remedies such as Tylenol, cough medicine, etc., in dosages appropriate for his/her age, and to clean and bandage or wrap wounds as necessary


I represent that this health history is correct to the best of my knowledge, and the minor child herein described has permission (and I hereby authorize the Event Directors of its agents) to engage in all prescribed activities associated with the Event as noted by me and/or my physician. I hereby give permission to the physician selected by the Event Director (or his/her representative) to order X-rays, routine tests, and treatment for the health of my minor child and to order injection and/or anesthesia and/or surgery for my child named above. This authorization is given pursuant to Section 25.8 of the Civil Code of California. This authorization shall remain effective through the extent of the scheduled Event, unless sooner revoked in writing and delivered to said agent. I further agree that Calvary Chapel South Bay, Inc., its Board of Directors, officers, and staff are hereby relieved of any and all liability in the event of accident or injury to said Minor and his/her parents and/or guardians.

Relationship to minor (A signature box will appear after you check one of the boxes)