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Canobie Lake Park

June 28 2011

My child, has permission to attend the event at

Six Flags New England sponsored by Bethany Covenant Church.

I understand that every effort will be made to protect and safeguard all par-
ticipants. Therefore, I agree not to hold Bethany Church or any of its staff
and chaperones liable for any illness or mishap occurring in transport to
and/or during the event. I understand that adult supervision is being pro-
vided for the event and I authorize any treatment by an accredited hospital
and/or physician if it is deemed necessary for my child. I understand I will
be responsible for picking up my child at any time if my child becomes un-

Parent/Guardian signature (date) phone

Don’t forget page 2!

Return by June 12
Cost: $35
Be at church by 9 am on June 28
Medical Release Form

Bethany Covenant Church wants to assure you and your child that they will receive the
best possible care in the event of an accident. We would like to have a copy of any
medical conditions or awareness’ that would benefit us in treating your child either in
route to or from our excursion. This form will be with Bethany counselors at all times
and will be used to help treat your student should a need for treatment arise.

I authorize any treatment by an accredited hospital and or physician if it is deemed nec-

essary for my child.

Parent/ Guardian Signature_______________________________________________

Student’s name_________________________________________________________

Chronic health problems/Allergies:__________________________________________


Special medications used:________________________________________________


Medical Insurance Company_________________________________

Phone Number______________________

Policy Number____________________________________

Parent or legal guardian contacted in case of an emergency:_____________________

Phone number:________________________________

I want to emphasize the importance we are placing on your child’s safety and well be-
ing. In the event of an emergency we want your child to receive the best and quickest
health care possible.