Northwest Community Church
Permission Slip for Year-Round Activities
What is your Child's Full Name?
*
First Name
Last Name
What is your child's Date of Birth?
*
-
Month
-
Day
Year
Date
How old is your child?
Sex
*
Please Select
Male
Female
Parent / Guardian Information
What is your address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Email Address
*
example@example.com
Mother/Legal Guardian Name
*
First Name
Last Name
Father/Legal Guardian Name
First Name
Last Name
Emergency Contact Information
Emergency Contact 1 Name
*
First Name
Last Name
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Emergency Contact 2 Name
First Name
Last Name
Emergency Contact 2 Phone
Please enter a valid phone number.
How did you hear about Northwest?
Please Select
Flyer
Social Media
Friend or Family
Other
Would you like to be added to our email list?
Yes
No
What church do you normally attend?
Medical Release
PARENT: Do you give permission for your child to be treated for injuries or illnesses during this activity? If so, please choose yes. Should Injury or illness occur we will make every effort to contact you, but we need your permission to treat minor problems and medical emergencies.
*
Please Select
Yes
No
MEDICAL RELEASE: Should emergency medical treatment be necessary during this activity, I hereby grant consent to approved church leaders and chaperones to seek the following medical treatment to my child: medical or surgical examination, any anesthetic, and treatment of any medical need diagnosed by a duly licensed physician or surgeon. Consent is given in advance of any specific diagnosis.
*
Child's Medical Information
Does this child have any allergies, health problems that require medication or a special diet, or special considerations we should be aware of?
*
Please Select
Yes
No
Does your child have any allergies?
Does your child take any Medications?
Are there any special diet considerations?
Are there any other special considerations we need to know about?
Can this child walk home alone?
*
Please Select
Yes
No
Who are the approved pick up persons other than yourself?
*
Signature
Your signature signifies approval and permission for your child to attend and participate in all activities at or sponsored by Northwest Community Church including, but not limited to: Safe Haven Program, Nursery, Sunday School Classes, Children's Church, Jr. Church, VTA, Open Court Basketball, Basketball Camp, Camp Hope, Soccer Camp, etc. Your signature also gives approval for the approved church leaders and chaperones to seek medical treatment in the event of a medical emergency. Your signature on this form also signifies that you are aware of the inherent risk of injury and approve of your child attending. Finally, by signing this, you also allow for pictures/videos of your child to be used in promotional materials for Northwest Community Church.
Parent / Legal Guardian Signature
*
Participant Signature: Your signature signifies that you agree to the rules, policies, and guidelines for this activity and that you will cooperate fully with church leaders.
Continue
Continue
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