Permission-Girl | Awakening of Bryan Ohio

Girl's Permission Slip & Medical Information (#12)

Sleeper Information:

Sleeper's Name

Last Name

Sponsor's Name

Sleeper's Address

Address Line 1

Address Line 2

City

State

Zip Code

Sleeper's Phone Number

Date of Birth

Parent's Name

Parent's Phone

Emergency Contact

(Other than parent)

Parent's Name

Parent's Phone

Contact's Phone

Medical Information:

Any known allergies?

Yes

Please List Allergies:

Any current medications?

Yes

Please List Medications and schedule:

Insurance Carrier

Group Number

Account Number

Preferred Medical Facility

I, give my permission for my son/daughter, , to participate in the Awakening weekend. I also give permission to the director(s) of the Bryan Awakening Community, to seek medical attention for my son/daughter if deemed necessary. In the event of an emergency, I will be notified as soon as possible at the phone number(s) listed above.

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