Permission Slip Form

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Phone Number

Please enter a valid phone number.

Parent/Guardian Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Child*

First NameLast Name

As a parent or legal guardian, I hereby give permission for my child to participate in (Type event name below) with Mt. Zion Baptist Church

As a parent or legal guardian, I hereby give permission for my child to participate in blank (Event Name), on the date of Date with Mt. Zion Baptist Church.

I further authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical, or dental diagnosis and treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advise of any licensed physician or dentist. I agree to be liable and agree to pay all costs an dexpenses incurred in connection with such medical and dental services.

I also give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrested while attending and participating in the above event.

Furthermore, i give my consent and permission for the taking of phototographs and/or video of myself or my child in the MZBC function stated above. I also acknowledge that the sole puprose of the photographs and/or video taken is to be used for church related media only. Therefore, I assign any and all rights of such media to MZBC.

In no way shall I hold Mt. Zion Baptist Church and its represntatives accountable for any injury and/or subsequent expense incurred by the participant. By signing below, I acknowledge and accept the risks of injury associated with participation.

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

Signature of Participant

Signature of Parent