Date of Activity:  Date*   Activity*   Location*   

Parental Permission and Release
As a parent or legal guardian of (child’s full name)   First Name*   Last Name*   
I give permission for him/her to participate in any activity of City on a Hill, except for those that I have designated in writing on this form below. I give permission for my child to ride in a vehicle of a staff member or volunteer of City on a Hill and participate in field trips for which I receive written notification. I acknowledge by my signature below my child/children’s voluntary participation in the activities of City on a Hill and give permission for their photograph/video image to be included in promotional materials used by the organization. I understand that City on a Hill’s goal is to improve the lives of children and families in central city neighborhoods by providing holistic services based on Christian principles and values. I support their purpose and agree that my child/children are expected to honor the authority of the staff and those in leadership during their participation in program services and activities.

Medical
In case of an emergency, I give City on a Hill representative’s permission to render first aid and/or seek treatment for my child/children in a medical care facility; I give the medical care provider permission to administer the necessary treatment and I accept full financial responsibility for any services rendered.

Hold Harmless
I hereby acknowledge the ordinary risks incidental to the nature of the programs and activities in which my child/children participate, including risks that are unforeseeable. I agree by my signature below that I will hold harmless and indemnify City on a Hill, its directors, employees, agents and/or associates from any and all liability. I will be responsible for any damage or loss to physical property or expenses incurred due to negligent or irresponsible behavior on the part of my child/children.

Donated Goods Policy
City on a Hill’s policies prohibit giving donated merchandise to volunteers or staff in exchange for labor or services rendered. Volunteers are not permitted to remove any materials or equipment from the premises of City on a Hill for personal use.

In case of emergency, please call:     First and Last Name      at   phone       

List any physical, mental, or emotional problems of your child:   Type here   

List any medications, foods or substances which he/she are allergic:   Type here   

List any activities that your child may NOT participate in with City on a Hill or its representatives:    Type here