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.

YesNo

Allergies/Medical Conditions*

YesNo

2nd Child's Name*

First NameLast Name

2nd Child's Birthday*

MonthDayYear

Please provide a photo of your child for our records.*

YesNo

Allergies/Medical Conditions*

YesNo

3rd Child's Name*

First NameLast Name

3rd Child's Birthday*

MonthDayYear

Please provide a photo of your child for our records*

YesNo

Allergies/Medical Conditions*

YesNo

4th Child's Name*

First NameLast Name

4th Child's Birthday*

MonthDayYear

Please provide a photo of your child for our records*

YesNo

Allergies/Medical Conditions*

YesNo

5th Child's Name*

First NameLast Name

5th Child's Birthday*

MonthDayYear

Please provide a photo of your child for our records*

YesNo

Allergies/Medical Conditions*

I am the parent/guardian of the above child(ren).I hereby give my permission for my child(ren) to ride the church bus, participate in activities and attend Apostolic Temple of Cuyahoga Falls (Akron) and church related functions.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.I authorize the staff or designated medical professionals and/or volunteers to administer emergency medical assistance for my child(ren) if I cannot be reached.

Signature