BLAST KIDS BUS RIDER PERMISSION SLIP

Parent/Guardian Name

First NameLast Name

Parent/Guardian Phone Number

Please use a phone number that we can use to contact you in the event of an emergency.Format: 0000000000.

Address

Street Address

Street Address Line 2

City

Zip Code

Please select Bus Captain

1st Child’s Name

First NameLast Name

1st Child's Birthday

MonthDayYear

Please provide a photo of your child for our records.

Does your child have any allergies or medical conditions

Allergies/Medical Conditions

Do you have any other children that will be riding?

2nd Child's Name

First NameLast Name

2nd Child's Birthday

MonthDayYear

Please provide a photo of your child for our records.

Does your 2nd child have any allergies or medical conditions

Allergies/Medical Conditions

Add 3rd Child?

3rd Child's Name

First NameLast Name

3rd Child's Birthday

MonthDayYear

Please provide a photo of your child for our records

Does your 3rd child have any allergies or medical conditions

Allergies/Medical Conditions

Add 4th Child?

4th Child's Name

First NameLast Name

4th Child's Birthday

MonthDayYear

Please provide a photo of your child for our records

Does your 4th child have any allergies or medical conditions

Allergies/Medical Conditions

Add 5th Child?

5th Child's Name

First NameLast Name

5th Child's Birthday

MonthDayYear

Please provide a photo of your child for our records

Does your 5th child have any allergies or medical conditions

Allergies/Medical Conditions

I, undersigned, agree with the following statements:

I understand that my child(ren) will be under adult supervision and that in signing this permission slip I release and hold harmless Apostolic Temple of Akron, it's trustees, officers, employees, interns, and any volunteers (collectively herein the "church") from any and all liability, claims or demands for accidental personal injury, sickness (including but not limited to Covid-19) or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant while involved in the activities.

Signature