1. Lake Houston United Methodist Church
Youth Activity Permission Slip
SECTION I. I, the lawful parent or guardian of _________ (the “child”), give permission for
my child to participate in the activity described below and release from all liability and indemnify Lake Houston United Methodist Church
(LHUMC) and all youth ministry staff and/or volunteers, both individually and as trustee LHUMC from any and all liability, claims,
judgments, cost or expenses, including attorney fees, arising out of any injury or illness incurred by my child while participating in or
traveling to or from the activity. I agree to instruct my child to cooperate with the Lake Houston UMC youth ministry staff and volunteers
in charge of the activity.
I understand LHUMC and its youth ministry staff are committed to providing safe, fun and educational activities, and that all youth
activities are conducted in a smoke-, alcohol- and drug-free environment. In light of this, and to help ensure the safety of all concerned,
I understand that if my child is in possession of drugs, alcohol or tobacco products, engages in any illegal conduct, or refuses to follow
the directions of LHUMC youth staff or volunteers while participating in this activity, I will be telephoned to immediately pick up my child.
Activity: We will be going to Deerbrook Mall and Cici’s Pizza in Atascocita on November 9th. Meet at
the church at 4:00 PM and arrive back around 7:15 PM. Bring enough money for Cici’s Pizza.
SECTION II. Parent/Guardian Name: _______________________________________________________________________
Parent's Telephone: __________________________________________ Cell: _________________________________________
If I am unreachable in an emergency, contact: ___________________________________________________________________
Relation to Student: __________________________________________ Emergency Telephone: __________________________
Cell: __________________________________________
_____ I have provided medication for my child to take with the supervision of the adult in charge.
Medication: _____________________________________ Dosage: ___________________ How Often: ____________________
SECTION III. I hereby grant permission for my child to participate in the above mentioned activity and agree to any and
all guidelines as stated.
Parent/Guardian Signature: ___________________________________________________________________________________
Date: ______________________________________________________________________________________________________