Annual Youth Permission Slip
Please complete a SEPARATE form for each participant. This must be completed every school year for meetings and events at the church. Parental Consent and Medical Release through July 31, 2026. Activity Participation Agreement.
Parent/Guardian #1
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Parent/Guardian #2
First Name
Last Name
Email
example@example.com
Cell Phone Number
Please enter a valid phone number.
Participant Name
*
First Name
Last Name
Birth date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant's Phone Number
If applicable to the child.
Emergency Contact: (please list someone other than a parent/guardian
*
First Name
Last Name
Emergency Contact Relationship:
*
Phone Number
*
Please enter a valid phone number for the emergency contact.
If a minor, does the participant have the permission of the custodial parent or legal guardian to attend this event?
*
Yes
No
Are event sponsors/leaders authorized to approve medical treatment?
*
Yes
No
Is the participant covered by personal/family medical insurance?
*
Yes
No
Name of Insurance:
Example: United Healthcare
Member ID
Policy or group number:
Name of responsible party and relationship
Please list any concerns regarding the participant's allergies, medications, or restricted activities for which we should be aware:
I understand that if at any time the participant’s insurance changes, I, the custodial parent or legal guardian, must notify the Director of Youth and Children’s Ministries to request and complete a new permission slip with the updated medical information before the participant can participate in any youth events.
*
Yes
No
Signature
By signing below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation in scheduled youth group activities both at the Saint Matthew’s and offsite from 7/1/25 – 7/31/26.
I affirm that my health is good, and that I am not under a physician’s care for any undisclosed condition that bears upon my fitness to participate in in these activities, and if a change in my current condition arises, I will notify the youth leaders of said change. I understand that each participant must assume the risk of physical injury that could result from any of these activities. Except for gross negligence on the part of the sponsor, the participant (or parent/legal guardian) accepts personal financial responsibility for any and all bodily or personal injury sustained during said activities. Further, the participant (parent/guardian) promises to hold harmless the sponsoring organization, staff, volunteers, and its representatives for any injury related to all Saint Matthew’s Youth activities from July 1, 2025- July 31, 2026. If a dispute over this agreement or any claim for damages arises, the participant (parent/guardian) agrees to resolve the matter through a mutually acceptable arbitration process.
I acknowledge and accept
*
Yes
No
Signature
Photo Release:
In addition to the above mentioned terms, I also I grant to Saint Matthew’s Episcopal Church, the right to take photographs of my child in connection with the above-identified event. I authorize Saint Matthew’s Episcopal Church to use and publish the same in print and/or electronically. I agree that Saint Matthew’s Episcopal Church may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I accept terms of photo release:
*
Yes
No
Signature
Submit
Should be Empty: