BICS Experience Day Permission Form

BICS Berkshire Institute
for Christian Studies
PO Box 1888 | Lenox, MA 01240
413-637-4673 | berkshireinstitute.org
BICS Experience Day Permission Form
This form is required for all visiting students under the age of 18. Please complete it before joining us for Experience Day.
Student Information
Full Name:*

First NameLast Name
DOB:*

MonthDayYear
Date
Student Cell Phone:
Format: (000) 000-0000.
Please list any medical conditions, allergies, required medications, & special accommodations needed while with us:
Please note: BICS staff will not give any medication to a participant and medical staff is not available on the premises. In the event of an emergency, 911 and emergency contacts will be called to respond.
Parent/Guardian Information
Full Name of Parent/Guardian:*

First NameLast Name
Email Address:*
example@example.com
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Format: (000) 000-0000.
Is the Parent/Guardian the Primary Emergency Contact?

YesNo
Primary Emergency Contact Name:*
Relationship:*
Phone Number:*
Format: (000) 000-0000.
Secondary Emergency Contact Name:*
Relationship:*
Phone Number:*
Format: (000) 000-0000.
Permission
- I give permission for my child, named above, to visit the Berkshire Institute for Christian Studies and to participate in the BICS Experience Day, including an overnight stay in the BICS residence facilities (located in Pittsfield, MA). I understand that this includes transportation to/from the BICS dorms. I further understand that my child is expected to abide by all BICS policies/conduct guidelines for the duration of his/her visit.
- In case of emergency, and if I cannot be reached, I, the undersigned parent/guardian of the above-named child, do hereby authorize a representative of Berkshire Institute for Christian Studies to seek emergency medical treatment/care. In the event of an emergency, 911 and emergency contacts will be called to respond. I agree to hold the Berkshire Institute for Christian Studies free and harmless of any claims, demands or suits for damages arising from the giving of consent for medical treatment, and I also authorize my own responsibility for any and all medical bills.
- I hereby release, forever discharge, and agree to hold harmless the Berkshire Institute for Christian Studies, and the directors and staff thereof, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, or any nature whatsoever which may be incurred by the undersigned and/or the students that occur while said student is participating in the BICS Experience Day or similar campus visit.
- I hereby grant permission to the Berkshire Institute for Christian Studies to use, for promotional purposes, photographs and video in which my child appears (e.g., brochures, website, and other promotional presentations).
I, as parent/guardian of the above-named student, understand the release provisions stated above and hereby grant my permission:
Printed Name:*
Signature:*
Date:*

MonthDayYear
Date
If you have any questions, please contact us by phone or email. We look forward to hosting you!
Should be Empty:

BICS Experience Day Permission Form

Student Information

Parent/Guardian Information

Permission