TRAVEL PERMISSION & MEDICAL AND SURGICAL WAIVER

To be completed by parents or legal guardians of participants under 18 years of age:

I,                                                                , parent and/or legal guardian of                                                              , a minor, hereby acknowledge that said minor is presently under my care, custody, and control.  I hereby give my child, the said minor, my express permission to attend and participate in all activities and events sponsored by The Student Ministry at First Baptist Church of McAllen, Texas, from January 1, 2005 - December 31, 2005.  I further expressly grant my permission for my child to participate in all activities of the trip.

In the event there arises an emergency, necessitating medical or surgical attention, I hereby consent and give my permission to First Baptist Church of McAllen or its representatives, the trip sponsors, or any attending physician to make such decisions and to perform such medical treatments and/or surgery upon said minor which may in their sole discretion be necessary and proper under the circumstances.

I so release, acquit, discharge, and covenant to hold harmless the First Baptist personnel, or its representatives from any and all actions, damages, liabilities arising out of the treatment of any sickness or accident incurred by my said child during the above dates.

I understand that my son/daughter will be dismissed from the trip and sent home at my expense if he/she does not adhere to the rules.

Parent and/or Guardian                                                                           Date                                 

Address                                                                                                     Phone          /                   

Emergency Contact                                   Relation                                 Phone         /                    

Date of last Tetanus Shot                                             

Physical limitations (asthma, diabetes, migraine headaches, allergies, etc.)                                                                                                                                                                                                                                                         Special instructions which might be helpful to physician (Medicine allergies, rare blood type, etc.)                                                                                                                                                                                                                       

Insurance Company Name                                                                                                                                           

Policy Number                                          

Signature:                                                    

IN WITNESS WHEREOF I hereunto set my hand and affixed my official seal

this                        day of             , 20          

Notary Public in and for the State of Texas

My Commission expires: