Student/Child Permission Form

Student/Child Permission form (up to age 21)
(Includes Medical & Photo Release)

student/child information

* Indicates required field

Student/Child Name *

First

Last

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Health Insurance Provider *

Policy Number *

Are there any special needs or health conditions of which Sharon Baptist Church should be aware? *

Yes No

List of Special Needs and/or Health Conditions *

Does your child know how to swim? *

No Yes - Beginner Yes - Intermediate Yes - Advanced

parent/guardian 1 information

Parent/Guardian 1 Name *

First

Last

Relationship with Student/Child *

Mobile Number *

Home/Work Number *

parent/guardian 2 information

Parent/Guardian 2 Name *

First

Last

Relationship with Student/Child *

Mobile Number *

Home/Work Number *

emergency contact information

The Emergency Contacts (EC) will be contacted in an urgent matter when the parents/guardians cannot be reached.

EC1 Name *

First

Last

EC1 Phone Number *

EC2 Name *

First

Last

EC2 Phone Number *

Medical care authorization

As the parent (or guardian) of the above-named attendee of Sharon Baptist Church’s student/children activities, I hereby authorize Sharon Baptist Church and its chaperones to seek and have emergency medical first aid administered to the above-named attendee.

Parent/Guardian Name *

First

Last

Date *

waiver of publicity

I give permission for the use of any photos, movies, and audio or video recordings of my child’s activities in connection with
Sharon Baptist Church’s student/children's ministry, to be used with Sharon Baptist Church’s approval for educational or religious purposes, media coverage, or for publicity benefiting educational or religious purposes.

Parent/Guardian Name *

First

Last

Date *

permission & release

As the parent (or guardian) of the above-named attendee, I grant permission for my son or daughter to attend Sharon
Baptist Church’s activities and events and authorize Sharon Baptist Church and its chaperons, to transport and
supervise my child in connection with his or her attendance at the various activities.

I do further hereby give, release, absolve, indemnify, and agree to hold harmless, Sharon Baptist Church, its trustees, staff,
volunteers, and persons transporting my son/daughter to and from the activity and associated activities from any claim
arising out of injury to my son or daughter, except to the extent such harm is the result of the intentional misconduct of
Sharon Baptist Church or such other party seeking to enforce this release.

Parent/Guardian Name *

First

Last

Date *

Submitting this form constitutes your legal signature on the above information.

I agree to receiving marketing and promotional materials

Submit