Brock UMC 2019-2020 Children & Youth Permission Slip
2019-2020 Church Participation and Transportation Permission Slip and Liability Wavier. This form is to be filled out and signed by a parent or legal guardian BEFORE any child may ride the church van and/or
participate in any activities at Brock United Methodist Church.
Parent/Guardian First Name *
Your answer
Parent/Guardian Last Name *
Your answer
Second Parent/Guardian First Name
Your answer
Second Parent/Guardian Last Name
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian's Primary Phone Number *
Your answer
Parent/Guardian's Secondary Phone Number
Your answer
Parent/Guardian's Email Address *
Your answer
Name of anyone else with permission to pick up your child(ren) from the church
Your answer
Name of anyone else with permission to pick up your child(ren) from the church
Your answer
Child's (Participant's) First Name *
Your answer
Child's (Participant's) Last Name *
Your answer
Child's (Participant's) Sex *
Child's (Participant's) Date of Birth *
MM
/
DD
/
YYYY
Child's (Participant's) Grade *
Does your child (participant) have food allergies? *
List Allergies:
Your answer
Does your child (participant) have (a) medical condition(s) of which the church should be aware? *
List Medical Conditions
I hereby give my permission for all children listed above to ride the van, participate in activities, and attend Brock United Methodist Church or any other church related functions. I understand that my children will be under adult supervision. I further understand that by initialing this permission slip, I release and hold harmless Brock United Methodist Church and all other church related functions. By initialing this permission slip, I release and hold harmless the trustees, officers, employees, and any volunteers of Brock United Methodist Church from any liability, past or future, fully and completely. I authorize the staff or designated medical professionals and/or volunteers to administer emergency medical assistance if I cannot be reached, or until I arrive. *
Please Initial (First, Middle, Last) Below
Your answer
Submit
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