Haysville United Methodist Church

 

MINOR: I/we __________________________________________________________ declare that I/we am/are the lawful Guardian of
                                                                          Parent(s)
____________________________________________________. A ______ citizen of the United States, born __________________,
                         Child Name Sex Date
in__________________________________________.
                                        City & State

I have legal authority to grant travel consent to the Traveling Guardians listed below for the Child:

 

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Appointed Attorneys Of Haysville UMC Youth of Haysville, Kansas

Main Destination: ____________________________________________________________________________
Duration/Dates of Travel: ______________________________________________________________________
1. Additional contact information is contained on the Emergency Information sheet also in the possession of the Haysville UMC Youth Traveling Guardians.
2. Should it prove to be impossible to notify the Parent / Guardian of any change in travel plans due to an emergency or unforeseen circumstances arising, I authorize the Traveling Guardian(s) to authorize such change in travel plans.
3. Should the Traveling Guardian(s) in his / her sole discretion (which discretion shall not be unreasonably exercised) deem it advisable to make special travel arrangements for the Child to be returned home due to any unforeseen circumstances arising, I accept full responsibility for the additional costs which shall be incurred thereby.

 

ADULT: I ________________________________________________
                                                      Adult Participant
CERTIFY that I/We have made, constituted and appointed, and by these presents do make, constitute and appoint any of the above Traveling Guardians individuals as my/our true and lawful attorneys, said attorneys having authority to act individually in fact for me/us and in my/our name(s), place(s) and stead(s) to give any medical doctor or hospital consent to give any and all medical attention and services, of every nature, to and for my/our said child above named deemed necessary by my/our said attorneys, giving unto my/our said attorney full power for one year to do everything whatsoever requisite and necessary to be done in the premises as fully as I/we could do if personally present without limitation, my/our acknowledgment of my/our personal liability for all reasonable charges for all such medical services, release of medical records and/or attention furnished at the request of my/our said attorneys-in-fact.

Parent/Guardian Signature __________________________________________________________________________________

 

Parent/Guardian Signature __________________________________________________________________________________

 

Participant Signature ______________________________________________________________________________________

 

    STATE OF KANSAS )
    COUNTY OF SEDGWICK )

    BE IT REMEMBERED THAT ON THIS _______ day of ____________, 20___, before me, the undersigned, a Notary Public in and for      said County and State, came _________________________________________, who is/are known to me to be the same

    person/s     who executed the foregoing instrument of writing, and such person/people duly acknowledge/s the execution of the

    same.

 

     IN WITNESS WHEREOF, I have hereunto set my hand and affixed by official seal the day and year last above written.

    _______________________________________
                             SEAL Notary Public