CAMPUS LIFE PERMISSION FORM

CAMPUS LIFE

PERMISSION SLIP
I give permission for my child to take part in Campus Life Club after school. I certify that my child can participate in this activity and have listed any restrictions below.
STUDENT NAME
SCHOOL
GRADE
AGE
DATE OF BIRTH

MonthDayYear
Date
Address

ADDRESS

Street Address Line 2

CITYState / Province

ZIP
STUDENT'S CELL
STUDENT'S EMAIL
example@example.com
Campus Life ________________________permission to use photos and videos of my child. Occasionally our Campus Life Club ay travel to another location to meet or go somewhere for a special event or activity. I give permission for the staff of Mason-Dixon YFC/Campus Life Club to transport my child to alternate meeting locations, special events and activities. I do not give permission for the staff of Mason-Dixon YFC/Campus Life Club to transport my child to alternate meeting locations, special events and activities.

DoesDoes Not
Occasionally our Campus Life Club may travel to another location to meet or go somewhere for a special event or activity.

I give permission for the staff of Mason-Dixon YFC/Campus life Club to transport my child to alternate meeting locations, special events and activities.I do not give permission for the staff of Mason-Dixon YFC/Campus life Club to transport my child to alternate meeting locations, special events and activities.
Primary Emergency Contact
Parent/Guardian Name (Mother)
Home Phone
Cellphone
Email
example@example.com
What is the best way to reach you? Circle all that apply. List the preferred method.

CallTextEmail
Please write your preferred method (Call, Text, Email)
Secondary Emergency Contact
Parent/Guardian Name (Father)
Home Phone
Cellphone
Email
example@example.com
What is the best way to reach you? Circle all that apply. List the preferred method.

CallTextEmail
Please write your preferred Method (Call, Text, Email)
Date

MonthDayYear
Date
Parent/Guardian Signature

Clear
Should be Empty:

CAMPUS LIFE

Primary Emergency Contact

Secondary Emergency Contact