Victory Worship Center
                 Permission Slip

Please print this page, fill it out, and give it to Pastor Shawn. This is for parents to give permission for youth trips. Note* this permission slip must be signed by a parent or legal guardian to be valid.

Name ___________________________________________________________________

Address__________________________________________________________________

City______________________________ ST ____ Zip ____________ 

Parent/Legal Guardian _______________________________________________________

Phone (___)____-_______________

If a Parent or Guardian cannot be reached, in the event of an emergency, call:

Name/Phone/Relationship

1.)______________________________________________________________________

2.)______________________________________________________________________

History of past/present illness 

Allergies _________________________________________________________________

_________________________________________________________________________

Does your child take any medication at the present time? Yes  No  If yes, what and how often?  
1.__________________________________,

2.__________________________________,

Employer__________________________________________________________________

Insurance Co._______________________________________________________________

Policy Number______________________________________________________________

   I hereby grant permission to any qualified physician, to furnish such medical care as my son/daughter may require, including examinations, treatment, immunization, and so forth. This permission is conditioned upon the understanding that in the event of a serious illness or the need of hospitalization and/or surgery, the physician from providing such emergency treatment as may be necessary for the best interest of the life of my son or daughter.                                             

Signature of Parent or Guardian:________________________________  Date:_____________