Northwest Community Church Permission Slip for Year-Round Activities - English What is your Child's Full Name?* First NameLast Name What is your child's Date of Birth?* -Month -DayYearDate How old is your child? Sex* Please Select Male Female Parent / Guardian Information What is your address?* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Home Phone Please enter a valid phone number. Cell Phone* Please enter a valid phone number. Email Address* [email protected] Mother/Legal Guardian Name First NameLast Name Father/Legal Guardian Name First NameLast Name Emergency Contact Information Emergency Contact 1 Name* First NameLast Name Emergency Contact 1 Phone Number* Please enter a valid phone number. Emergency Contact 2 Name First NameLast Name Emergency Contact 2 Phone Please enter a valid phone number. Medical Release PARENT: Do you give permission for your child to be treated for injuries or illnesses during this activity? If so, please choose yes. Should Injury or illness occur we will make every effort to contact you, but we need your permission to treat minor problems and medical emergencies.* Please Select Yes No MEDICAL RELEASE: Should emergency medical treatment be necessary during this activity, I hereby grant consent to approved church leaders and chaperones to seek the following medical treatment to my child: medical or surgical examination, any anesthetic, and treatment of any medical need diagnosed by a duly licensed physician or surgeon. Consent is given in advance of any specific diagnosis.* Child's Medical Information Does this child have any allergies, health problems that require medication or a special diet, or special considerations we should be aware of?* Please Select Yes No Does your child have any allergies? Does your child take any Medications? Are there any special diet considerations? Are there any other special considerations we need to know about? Can this child walk home alone?* Please Select Yes No Who are the approved pick up persons other than yourself?* Signature Your signature signifies approval and permission for your child to attend and participate in all activities at or sponsored by Northwest Community Church including, but not limited to: Safe Haven Program, Nursery, Sunday School Classes, Children's Church, Jr. Church, VTA, Open Court Basketball, Basketball Camp, Camp Hope, Soccer Camp, etc. Your signature also gives approval for the approved church leaders and chaperones to seek medical treatment in the event of a medical emergency. Your signature on this form also signifies that you are aware of the inherent risk of injury and approve of your child attending. Finally, by signing this, you also allow for pictures/videos of your child to be used in promotional materials for Northwest Community Church. Parent / Legal Guardian Signature* Participant Signature ContinueContinue Should be Empty:
