JOY CHURCH PERMISSION FORM 2017-2018
Activities Permission Slip For Joy Church 1435 Saint Croix Street, Prescott, WI 54021
Student Information
Student Name *
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Age *
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Birth Date (MM/DD/YY) *
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Gender *
Address *
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City
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State
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Zip Code
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Student Cell #
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Texting
Parent/Guardian Information
Parent/Guardian Name *
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Address (if Different)
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Cell # *
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Texting
Email *
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Additional Parent/Guardian Name
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Cell #
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Texting
Email
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Emergency Contact Information
Name *
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Cell # *
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I give my permission for my child to participate in church activities with Joy Lutheran Church, Prescott, Wisconsin, and confirm my understanding of the following:
My son/daughter may be away from Joy Church Facilities. For different activities church groups may travel away from church property.

There is inherent risk of injury. Joy Church offers a variety of activities, which present inherent risk of physical injury. My son/daughter and I agree that he/she will follow directions of adult leaders and will act within the parameters of safe behavior whenever specific instruction are not given.

I authorize adult leaders to approve emergency medical treatment. In case of emergency, I understand that every effort will be made to contact me. If this is not possible, I give adult leaders my permission to act on my behalf in approving emergency medical treatment. I understand that I am responsible for the cost of all medical or hospital care or treatment to be rendered to my child and i have included our insurance company and policy numbers should medical treatment be necessary.

Parent/Guardian Electronic Signature *
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Student Electronic Signature *
Your answer
Electronic Date Stamp (MM/DD/YYYY) *
Your answer
Insurance Information
Medical/Health Insurance Company
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Policy Number
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My Child's Health Concerns
Allergies/Allergic reactions
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Medicine being taken by my child
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Other information regarding my child's health that a doctor should know
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Photographic Image Release
I hereby grant permission to use my child's likeness in photographs, video recordings, or electronic images in any and all of Joy's publications/communications, including website entries, without payment or any other consideration. I understand and agree that these materials will become the property of Joy and will not be returned.
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