The Movement General Permission Slip

Student's Name*
Date of Birth*
MM slash DD slash YYYY
Grade*
Address*
Street Address City State ZIP Code
Emergency Contact #1 Name*
Emergency Contact #1 Phone*
Emergency Contact #1 Email*
Emergency Contact #2 Name*
Emergency Contact #2 Phone*
Emergency Contact #2 Email*
Health/Medical Insurance Co.*
Policy Number*
Medical Conditions*
Does the student have any medical conditions, food allergies or special needs that we should be aware of?
Medical Conditions Explanation*
Please explain
Which event(s) are you giving consent for?*
Consent Agreement*
As a parent/legal guardian. I have reviewed the information and give permission for the subject of this release to be involved in the overall activities of this event. I/We understand all reasonable safety precautions will be taken at all times by City Church for All Nations Youth Team. and its agents during the events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold City Church for All Nations, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
- I Consent
Today's Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

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