Form

Student Name

First NameLast Name

Activity

Date of Activity:

Date

Email:

Activity: Ally Youth

Date of Activity: May 29th, 2026

Time: 7:00 PM

Details of the Activity: We will be meeting at Philadelphia Pentecostal Church in Lewisporte for Ally! We will be having a worship service, a devotion, with snack and connection time afterwards. Our screened leaders/volunteers will be present for the duration of the event.

Students are responsible for their transportation to and from the event! Pickup time varies, and will be communicated to you during the event.

Dear Parent:

We are planning an activity as part of our programming that requires your permission prior to participation. We have provided you the details of the activity and request that you complete and sign the permission form. The safety of your Child is our primary concern. Precautions will be taken for their wellbeing and protection.

Student’s Name:

First NameLast Name

Date of Birth

Date

Address

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Parent’s Work Number

Please enter a valid phone number.Format: (000) 000-0000.

Health Card Number

Family Doctor

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

In case of an emergency, contact:

First NameLast Name

Emergency contact phone:

Please enter a valid phone number.Format: (000) 000-0000.

I hereby consent to the participation of my/our child(ren) in this supervised activity.

While every precaution is taken for the safety and good health, some sports and activities carry with them the inherent risk of personal injury beyond the risks associated with many of the recreational activities at Pentecostal Assemblies of Newfoundland and Labrador. I/we understand and accept these risks and agree that by allowing my Child to participate in those activities, he/she may be taking part in a recreational activity that presents the potential for personal injury.

I/we, the Parents or guardians named below, authorize the Pastor or one of Pentecostal Assemblies of Newfoundland and Labrador personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named below, undertake and agree to idemnify and hold blameless Pentecostal Assemblies of Newfoundland and Labrador, its personnel, its leaders and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Pentecostal Assemblies of Newfoundland and Labrador, as well as of any medical treatment authorized by the supervising individuals representing Pentecostal Assemblies of Newfoundland and Labrador. This consent and authorization is effective only when participating in or traveling to events of Pentecostal Assemblies of Newfoundland and Labrador.

I have read, understood and agree with above.

Activity:

Parent/Guardian Signature

Printed Name

Date

Letter of Informed Consent