April-June 2023 Youth Permission Slip

Child's Name (First & Last)

Preferred nick name? Leave blank if none

Child's Date of Birth (MM/DD/YYYY)

Child's Gender

Child's mobile phone (if applicable), otherwise type "N/A"

Child's Email Address, otherwise type

Permission Slip - Spring 2023

I, being the parent or legal guardian of the child named above, hereby consent to the participation of my child in the activites named below at Christian Life Church, Eliot ME. These events are sponsored by the Youth Ministry of Christian Life Church, Eliot ME.

I certify that my child is physically fit and able to participate in this event. I understand that transportation to and from this event may be by private cars. Understanding that reasonable care and safety standards will be upheld during the trip/event, I will not hold Christian Life Church, staff, or any adult chaperones on the trip responsible for any injuries to my child, travelling to, from, and during the event. I give permission for a chaperone to seek any reasonable medical help for my child should the need arise, understanding that I would be contacted as soon as possible.

The undersigned hereby releases and holds harmless Christian Life Church, Inc., their agents, pastors, staff, volunteers, and parents participating in the activities listed below: 1. From any and all liability for any mishap or injury to the child named herein from the time of departure to the time of return. 2. From any injury or damage resulting from the activity, mode of transportation, or the provider of any transportation, whether resulting from an accident or otherwise. 3. From any loss, destruction, or damage to any personal property.

In the event my child suffers a sudden illness, accident, or injury and neither parents nor guardians can be contacted, I give permission for any emergency treatment that is deemed necessary by a licensed physician.

By signing this permission form, I understand the following:
• Parents must provide a phone number where they can be reached during the event in case of an emergency.
• Parents will be called to pick up a child if the child leaves the building/property for any length of time and/or acts in a manner deemed unacceptable by the Youth Ministry's Leaders and/or Parent Chaperones.

Please select the activity you wish to give your teen permission to attend

All Youth Events in Quarter 2 Youth Group Hilltop Trip (April 21 from 5:45 to 8:00 p.m.) Youth Summer Lock-In (June 16 @6p until June 17 @8a)

I have read and agree to the above terms

I agree

Electronic Signature of Parent/Legal Guardian

Today's Date

Emergency Contact Information

Parent/Legal Guardian Name (First & Last)

Relationship to child?

Parent/Legal Guardian Email

This address will receive a confirmation email

Parent/Legal Guardian Primary Phone

Parent/Legal Guardian Address

Emergency Medical Information

Please list: (1) Name of Insurance plan, (2) Policy/group number, and (3) name of subscriber of plan. If no insurance, please indicate

Upload photo of front of insurance card

Upload (8MB)

Upload photo of back of insurance card

Upload (8MB)

Name of Primary Care Physician

Primary Care Phone Number

Any allergies or Medical Conditions? If not, type N/A

Is your child taking any prescriptions or OTC medicines? If no, please type N/A

Does your child need to take medication of any kind DURING THE EVENTS listed above? If not, type N/A (If so, please indicate name, dose, and times to take. All medicdation must be in original bottle).

Please indicate any over the counter medications that ARE APPROVED for use if given by a youth leader in the recommended dosage (check all that apply):

Imodium Claritin Benadryl Acetaminophen such as Tylenol Ibuprofen such as Advil Antacid None of the above

Do you have any questions or concerns about these events?

April-June 2023 Youth Permission Slip

Description

Please Fix the Following