Bus Ministry Transportation Permission Slip

Participant's Information

Participant's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number*

Cell Number*

E-mail*

example@example.com

Parent/Guardian Information

Name*

First NameLast Name

Home Number*

Cell Number*

E-mail*

example@example.com

Emergency Contact Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Alt. Phone Number*

Emergency Medical Information

Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the participant prescribed any medications? If yes, please explain any instructions.*

Is sponsor authorized to approve medical treatment?*

YesNo

Is participant covered by personal or family medical insurance?*

YesNo

If 'Yes', name of insurer

Policy Number

Participation Liability Acknowledgement 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 the activity described above. Except for gross negligence on the part of the sponsor, the participant (or parent / guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent / guardian) promises to hold harmless the sponsoring organization and all its representatives for any injury related to the activity. The sponsor will not be held responsible for any items lost or stolen during the activity. If dispute over this agreement or any claim for damages arises, the participant (or parent / guardian) agrees to resolve the matter through a mutually acceptable process of arbitration.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Media Release Authorization By signing below, the participant (or parent / guardian if participant is a minor) gives permission for the participant to be included in photographs, video, and any other media used to promote or report on the event or activity they have attended.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Bus Transportation Permission Slip