MHBC Permission and Waiver for Children/Youth

Parent/Legal Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
Add a different/additional emergency contact person
Emergency Contact

First NameLast Name
Emergeny Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Email
Yes, I give permission that my child(ren)’s/youth’s audio/video recording or other documentation with respect to the activity can be used in church advertisements.No, I do NOT give permission for my child(ren)’s/youth’s audio/video recording or other documentation with respect to the activity can be used in church advertisements.
Signature of Parent/Legal Guardian*

Clear
Date*

MonthDayYear
Date
All information on this form will be kept confidential, and will not be given out for any reason without the consent of the parent or guardian.
Should be Empty: