St. Mark Lutheran Church
Youth Activity Permission Form
I give permission for my child, ________________________
To attend the following activity ________________________
Sponsored by SHINE! (the St. Mark High School Youth Group).
I am familiar with the mode of transportation, the leadership accompanying the group,
and other circumstances of the trip.
I certify that my child is in good health and can participate in all normal activities of the group.
Listed are any health concerns regarding my child:
I understand that reasonable measures will be taken to safeguard the health and safety of the group
and that I will be notified as soon as possible in an emergency.
In case of sickness or accident I authorize the treatment by a qualified and licensed medical doctor
including hospitalization if necessary at my expense.
My child is expected to abide by the rules of the trip as set by the St. Mark leaders.
If leaders have a discipline problem with my child that they are unable to control,
I understand I will be contacted and my child will need to leave the activity at my expense.
I can be reached by phone during this activity at:
Phone # Phone #
Signature of Parent Date