Sixth Presbyterian Church
Youth Universal Permission Form 
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Student Name 
Student's Birthday
MM
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DD
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YYYY
Name of Primary Guardian(s) 
Phone Number of Primary Guardian(s)
Email of Primary Guardian(s)
Address (including zip code) of Primary Guardian(s)
Secondary Emergency Contact for Youth (please include phone number and relationship to the student)
Allergies
Other heath conditions or learning differences (will only be shared with staff and supervising adults who care for your student)
Partcipation Consent/Permission 
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the children and youth ministries of Central Presbyterian Church. I/We understand that there are inherent risks involved in any ministry or related event, and I/we hereby release Sixth Presbyterian Church, its Pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Sixth Presbyterian Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Please Enter Permission/Participation Consent Signature Below
Date of Permission/Participation Consent 
MM
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DD
/
YYYY
Please provide us with the Name of the student's Insurance Carrier and Policy Number
Name of Primary Care Provider
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