Planting Youth Consent Form
Open Door Baptist Church Released Time
Child's Information
If more than one child please fill out a form for each child. In order for us to be able to remind your child about Planting Youth it is important we have a phone number.
Name
*
First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Lunch Period
1st Lunch Period
2nd Lunch Period
3rd Lunch Period
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Parent/Guardian Name
*
Mom's First Name
Mom's Last Name
Parent/Guardian Name
*
Dad's First Name
Dad's Last Name
Primary Phone Number
*
Secondary Phone Number
Does the child have any known allergies?
*
If yes, then please specify it on the field above. If none then please enter N/A.
Acknowledgment and Waiver
Permissions
*
I allow and authorize (Open Door Baptist Church) to pick up my child from Elida Middle School and take them to Open Door Baptist Church at 3494 Diller Rd Lima Ohio 45807 for Biblical instruction during school hours.
I allow (Open Door Baptist Church) to feed my child lunch during this instruction time.
I understand that Open Door Baptist Church will assume responsibilities for my child during this instructional time period.
I acknowledge that all information I provided on this form is true and accurate.
By submitting this form I am acknowledging that I am over 18 years of age and/or the parent/legal guardian for the above named child.
Parent/Guardian Signature
*
Signed Date
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: