Macedonia Baptist Church
5286 Highway 150 East, Lincolnton, North Carolina 28092
Telephone: (704)-735-3287

Youth and Children’s Ministry Permission Slip

Student’s Name: _____________________________________________________________

Name of Parent or Guardian:_____________________________________________________


Home Phone:_______________________ Cell Phone:_________________________________

Medical Information
Health Conditions & Allergies____________________________________________________



Physician’s Name: ___________________________Phone Number:______________________

I am fully aware of and acknowledge that my child, named above, has permission to
participate in all 2015 activities sponsored by Macedonia Baptist Church. I know of no
impairment that would affect or be affected by my child’s participation.
In case of an emergency, representatives of Macedonia Baptist Church have my
permission to seek emergency medical treatment for my child at the nearest hospital. The
staff of said hospital has my authorization to provide treatment deemed necessary for the well
being of child.
I agree to hold Macedonia Baptist Church and its representatives free of liability for any
injuries, damages, or loss unless caused by willful or intentional conduct on the part of the
church or its representatives.
I also give my child permission to be a passenger in the Macedonia Baptist Church bus
or van depending upon the activity.

By my signature below, I attest that I am authorized to give consent for the child’s
participation in all 2015 activities sponsored by Macedonia Baptist Church.

Signature of Parent or Guardian:__________________________________________________