Worms permission slip for our Tulsa Zoo trip - April 2010
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Content
Tulsa Zoo
Baptist Tabernacle Worms
Permission Slip
This form is to be completely filled out and signed by a parent
or legal guardian before a child may participate in this event.
Please Print:
Parent or guardian name __________________________________________________________
Home Address ____________________________________________________ Apt. No. ____________
City ______________________________________________________ Zip ________________________
Home Phone __________________________________________ Alt. Phone _______________________
Please list everyone of your household who has your permission to attend Collinsville Baptist Tabernacle’s
Tulsa Zoo – Saturday, April 24, 2010
10am – 4pm
Cost: $10 + food
Teen’s Name
Relationship to you
Age
Date of Birth
___________________________ ________________
_______
_____________________
___________________________ ________________
_______
_____________________
Do any of the above have allergic reactions to any medications? Circle one
Yes
If so, please list their name(s) and the medication(s) to which they are allergic:
No
_____________________________________________________________________________________
Other Information: ______________________________________________________________________
I hereby give my permission for all listed above to attend this event and participate in all activities. I
understand that my child(ren) will be under adult supervision. I further understand that in signing this
permission slip, I release and hold harmless Collinsville Baptist Tabernacle, its trustees, officers,
employees, and any volunteers from any liability, past or future, fully and completely. I authorize the
executive staff or designated medical professionals to administer emergency medical assistance if I cannot
be reached.
Parent or legal guardian signature _________________________________________ Date ____________