(Please print, fill out and mail to: Daniel J. Forte, 24 Adams Lane, Wayland, MA 01778)
CHRISTIAN SERVICE BRIGADE
STOCKADE UNIT #1953
TRINITARIAN CONGREGATIONAL CHURCH
Medical Permission Slip: 2005 - 2006
Boy’s Name:__________________________________Tel. #__(____)_______________
Home Address____________________________________________________________
Family Doctor_________________________________Tel. # ( )________________
Emergency Contacts
Parent’s Name:___________________Home # ( )__________Work # ( )_________
Parent’s Name:___________________Home # ( )__________Work # ( )________
Other Contact:___________________Home # ( )___________Work # ( )________
Insurance Company______________________Policy #___________________________
Due to the active nature of the Stockade program, it is important that you identify any health condition of the Stockade member about which the leaders should know.
Any medication taken regularly? __________________ Epileptic seizures?____________
Bee Sting or other Allergies? ____________________ Diabetic Condition?____________
Heart condition?________________ Any restrictions on strenuous activities or other medical concerns for which leaders should watch?________________________________
________________________________________________________________________
I hereby give permission for my son to participate in any and all regularly scheduled activities of Stockade Unit #1953. I will not hold Trinitarian Congregational Church of Wayland, MA or the individual Stockade leaders liable for such accidents or injuries which may occur. I understand that in the event of an emergency, every effort will be made to notify me; however, in the event I am unable to be reached, I authorize whatever emergency medical procedures might be deemed necessary.
Parent’s or Guardian’s Signature________________________________________
Date_________________
