Assembly of God of Bayshore / Activities Permission Form
Child's Full Name
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First Name
Last Name
By checking below you give permission for your child to attend the following activity :
Date Night!
Price ($20 Non Refundable Deposit must be made by 2/6. Payments can be made by stopping by our church office or calling in @ 631-665-5241 with debit/credit card info)
Activity Site
Date of Event
Start Time
End Time
Purpose of Event
Food, fun and fellowship
Specific Activities Planned
Dinner, Glow in the dark dance party, Slime factory, Arts & Crafts, Edible Explorations, Themed experiences and so much more All proceeds go towards Mountain movers, Royal rangers, Missionettes year end trip
I, the parent/guardian of the student named above, hereby give permission for my child to take part in the activity described above. I understand that the following conditions apply:
a. I understand that I am responsible for getting my child to and from the site identified above. I understand that my child shall be accompanied by staff member(s) during the event.
b. I understand that my child is expected to behave responsibly and to follow the Christian conduct and values..
c. I agree and understand that I am responsible for the actions of my child, and I release the Assembly of God from all claims and liabilities that arise in connection with the activity, except if due to the negligence of church officials.
d. I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the event may act on my behalf and at my expense in obtaining medical treatment for my child.
d. I confirm that my child is medically fit and able to participate in all activities described above, except for the following activities: (please write "Yes" to confirm)
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e. I have indicated below any permanent or temporary medical or other condition(s) including special dietary and medication needs, or the need for visual or auditory aids, which should be known about my child: (please write "N/A" if this does not apply to your child)
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Emergency Contact Name:
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First Name
Last Name
Phone Number (1)
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Area Code
Phone Number
Phone Number (2)
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Area Code
Phone Number
Additional Contact
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First Name
Last Name
Phone Number (1)
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Area Code
Phone Number
Phone Number (2)
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Area Code
Phone Number
E-mail
Signature of Parent/Guardian
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Printed Name of Parent/Guardian
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First Name
Last Name
Date
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Month
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Day
Year
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