SPECIAL EVENT PERMISSION TO RIDE SHUTTLE FORM

BE SURE TO CLICK THE SUBMIT BUTTON AT THE BOTTOM OF THE FORM UPON COMPLETTION.

Number of family members that will be riding.*

Parent*

First NameLast Name

Phone Number*

Area CodePhone Number

Emergency Contact #*

Area CodePhone Number

Relationship & Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Child #1

AgeFirst NameLast NameGender

Child #2

AgeFirst NameLast NameGender

Child #3

AgeFirst NameLast NameGender

Child #4

AgeFirst NameLast NameGender

Child #5

AgeFirst NameLast NameGender

Child #6

AgeFirst NameLast NameGender

I (we) grant permission for the child/children listed above to ride the Church Shuttle To Westside Family Worship Center and return home following the service or activity attended.

I (we) understand that in the event medical treatment is required, every effort will be made to contact me. However, in the event I cannot be reached, I give my permission to the staff or sponsor to secure the services of a licensed physician to provide the care necessary for my child’s well being. I agree to release and discharge Westside Family Worship Center and its employees and volunteer representatives from any liability growing out of personal injuries, damage or pecuniary loss resulting or occurring during or from the aforementioned activity, and or in transit to and from said activity.

Please list any medical allergies, medications being taken, medical problems or other pertinent information.

Medications/Allergies/Medical problems or pertinent information - *

List what is applicable or type NONE - Do not leave this area blank

Signed by Parent/Guardian*

First NameLast Name

Student riding the Shuttle will abide by the rules:

No standing while bus is in motion. No loud talking. No stomping or loud clapping. Respect the Driver and ALL other adults on the Shuttle. Respect for everyone on the bus. Keep hands to yourself. Acceptable & Appropriate Language and Behavior that is respectful to Jesus. No profanity, crude or vulgar language. No deliberately hurtful name-calling. Respond immediately to directions from any adult involved in the bus ministry to insure the safety of the bus and all aboard. No food or drink on the bus. Modest dress (girls and boys) with no alcohol, tobacco, crude, obscene or inappropriate images or writing. No tobacco products, alcohol, Controlled substances, or weapons. No cell phones turned on. Cell phones are permitted for emergency contact with parents but must be turned off. This is to prevent harassing or inappropriate texting or calls being sent to or received from or on the bus. No Music or Video Devices to display or play inappropriate music or video images.

Failure to abide by these rules will result in riding privileges being revoked.

I promise to abide by the above-mentioned rules. If I fail to abide by these rules I know my privilege of riding the Shuttle will be taken away from me.

All children must read the above statement or be read to and sign.

Place a "X" next to each blank child signature

Child #1*

First NameLast Name

Child #2*

First NameLast Name

Child #3*

First NameLast Name

Child #4*

First NameLast Name

Child #5*

First NameLast Name

Child #6*

First NameLast Name

E-mail *