St. Peter’s Evangelical Church

The United Church of Christ

YOUTH MINISTRY OFF-SITE

PARENTAL AUTHORIZATION FORM

Youth’s Name: _____________________________________

Emergency Contact Number: __________________________

I give ________________ permission to participate in following activity:

(Youth’s first name)

Activity:

Depart Date/Time:

Destination:

Return Date/Time:

In the event of an emergency, if I cannot be contacted, I hereby authorize that emergency treatment may be administered.

Parent/Guardian Signature: __________________________ Date: _________