Youth Lock-In Activity Permission Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Friday and Saturday, February 20-21, 2026
7:00 p.m. - 7:00 a.m.

Students are asked to bring a snack or drink to share and $10, however, students who have never attended youth and are brought by a friend attend for free.

New Life Assembly of God
720 3rd Ave N
Ellendale, ND
701-349-5449

In addition to completing this form, if the Yearly Medical Release form has not been completed in the last year, that form must also be completed.

Student's Name *

Date of Birth *

Parent/Guardian's Name *

Best phone number to be reached at. *

Optional second phone number (work, cell, etc.)

Emergency Contact (other than above) Name and Relationship to child *

Emergency Contact Phone Number *

Optional Second Emergency Contact (other than above) Name and Relationship to child

Optional Second Emergency Contact Phone Number

MEDICAL INFORMATION: List any changes from the Yearly Medical Release form last completed
*

MEDIA RELEASE: Participant gives permission for photographs and videos taken of the Participant during the activities at the above named event sponsored by New Life Assembly to be used by New Life Assembly in publications or promotional campaigns. *

Yes

I agree to notify the Church in the event of any health changes, which would restrict my child’s/youth’s participation in any normal activities.

Required

By entering your name below, you are effectively providing your signature, indicating that you do hereby consent to the participation of your student in the above stated activity.

Required

This form has been approved and signed by a parent or guardian.

Required

Parent/Guardian signature *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Ellendaleag.org.

Does this form look suspicious? Report

Forms