Annual Permission Slip

Annual Permission Slip

This must be filled out once a year.
Full Name *

First Name Last Name
Age *
Date of Birth *

- Month - Day Year
Date

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *
Parent Name *

First Name Last Name
Phone Number *

- Area Code Phone Number
Emergency Contact

First Name Last Name
Phone Number

- Area Code Phone Number
I give permission for my child to attend and participate in this event sponsored and endorsed by the YouthMinistry department of Brush Prairie Baptist Church, 11814 NE 117th Ave.,Vancouver WA 98662. This includes permission to travel to and from the event if applicable and authorization for any necessary medical or dental treatment.I hereby release and agree to hold harmless Brush Prairie Baptist Church together with its agents and employees from all actions, causes, damages, claims, or demands which I, my heirs, executors, administrators or assigns may have against Brush Prairie Baptist Church for any and all personal injuries, oss, or damage, known or unknown, which my child may incur by participating in the above activities or outings. I, the undersigned, have read this release and understand its terms. I execute it voluntarily and with knowledge of its significance. The undersigned further agree to assume full financial responsibility for any and all charges incurred, specifically including ambulance, physician, hospital, and medication expenses.In the event of injury to the participant, I understand that the participant’s own medical insurance is primary and any Brush Prairie Baptist Church medical coverage may be secondary.
Parent/Guardian Full Name *

First Name Last Name
Parent/Guardian Signature *

First Name Last Name
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to all terms and conditions contained therein. *

I agree
Date *

- Month - Day Year
Date
Existing medical conditions and/ or physical restrictions
Allergies and/or medications
Date of last tetanus immunization
Name and Phone number of Physician
Insurance Carrier
Group ID Number
If you do NOT want photos of your child posted on Social Media please sign here

First Name Last Name
Should be Empty: