The Movement General Permission Slip

This field is for validation purposes and should be left unchanged.

Student's Name*

Date of Birth*

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*

Service Times

get the app

social

Service Times

get the app

social

Main Navigation

Service Times

Location

Contact

Service Times

Location

contact