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Hearts on Fire - 2025 - Permission Form
1
Child's Full Name
*
This field is required.
First Name
Last Name
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2
By checking below, you give permission for your child to attend the following activity :
*
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Hearts on Fire Trip - November 21-23, 2025
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3
a. I understand that my child is expected to behave responsibly and respectfully.
*
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Yes
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4
b. I agree and understand that I am responsible for the actions of my child, and I release CRBC from all claims and liabilities that arise in connection with the trip, except if due to the negligence of church staff.
*
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Yes
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5
c. I confirm that my child is medically fit and able to participate in all activities described above. Choose
No
, if you need to list any exceptions or activities your child cannot participate in.
*
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YES
NO
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6
Activities my child cannot participate in:
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7
d. My child has medical or dietary needs that the church needs to be aware of. (If you choose
Yes
, you will be able to list those next.)
YES
NO
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8
List any medical needs (including medications) or dietary restrictions. Include any relevant allergies as well.
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9
e. I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
*
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Yes
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10
Emergency Contact Name:
*
This field is required.
Probably you or your spouse.
First Name
Last Name
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11
Phone Number
*
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Area Code
Phone Number
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12
Additional Contact
*
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First Name
Last Name
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13
Phone Number
*
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Area Code
Phone Number
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14
Signature of Parent/Guardian
*
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By signing below you agree to all rules and conditions listed above. You can use mouse, or finger on touch screen device to enter signature.
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15
Name of Parent/Guardian
*
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First Name
Last Name
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16
Date
*
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-
Date
Month
Day
Year
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