Youth Permission Slip

Youth Event *

Please enter the name of the event:

Name of Student *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Date of Birth

Home Phone *If none, please enter 0.

Student's Cell Phone *If none, please enter 0.

Father or Guardian's Name

Mother or Guardian's Name

Parent's Cell Phone *

Parent's Email *

Name of Insurance *

ID Numbers *

Name of Primary Care Doctor *

Doctor's Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Doctor's Phone Number *

Medical Allergies or Conditions *Please describe any allergies or medical conditions the student has (including glasses or contact lenses) or state none.

Medications *Please include medications the student uses or state none.

Emergency Contact Name *

Emergency Contact Phone *

Parental Permission *

I give permission for my youth to participate in the above event. If emergency medical treatment is required, I give permission to the church staff or adult volunteers to obtain the services of a licensed physician. I will be notified as soon as possible concerning any such emergency. By typing my name here, I am electronically signing this form.

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<article class="left page-content post-6976 page type-page status-publish hentry"><p id="breadcrumbs"><a href="https://sterlingumc.org">Home</a>  ›  <a href="https://sterlingumc.org/resources/">Resources</a>  ›  <a href="https://sterlingumc.org/resources/youth-ministry-forms/">Youth Ministry Forms</a>  ›  Youth Permission Slip</p><h1 class="page-title">Youth Permission Slip</h1><div id="vfb-form-40" class="visual-form-builder-container"><form id="youth-permission-slip-40" class="visual-form-builder vfb-form-40 " method="post" enctype="multipart/form-data">
			<input type="hidden" name="form_id" value="40" /><fieldset class="vfb-fieldset vfb-fieldset-1 youth-connections-permission-slip " id="item-vfb-1073"><div class="vfb-legend"><h3>Youth Connections Permission Slip</h3></div><ul class="vfb-section vfb-section-1"><li class="vfb-item vfb-item-textarea  " id="item-vfb-1087"><label for="vfb-1087" class="vfb-desc">Youth Event  <span class="vfb-required-asterisk">*</span></label><div><span class="vfb-span"><label>Please enter the name of the event:</label></span><textarea name="vfb-1087" id="vfb-1087" class="vfb-textarea  vfb-medium  required ">

Name of Student *

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Date of Birth

Home Phone *If none, please enter 0.

Student's Cell Phone *If none, please enter 0.

Father or Guardian's Name

Mother or Guardian's Name

Parent's Cell Phone *

Parent's Email *

Name of Insurance *

ID Numbers *

Name of Primary Care Doctor *

Doctor's Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Doctor's Phone Number *

Medical Allergies or Conditions *Please describe any allergies or medical conditions the student has (including glasses or contact lenses) or state none.

Medications *Please include medications the student uses or state none.

Emergency Contact Name *

Emergency Contact Phone *

Parental Permission *

I give permission for my youth to participate in the above event. If emergency medical treatment is required, I give permission to the church staff or adult volunteers to obtain the services of a licensed physician. I will be notified as soon as possible concerning any such emergency. By typing my name here, I am electronically signing this form.

Media Release *

When participating in church activities, your child may be photographed for print, videotaped, or electronically imaged. Images may be used in promotional materials, news releases, and other published formats for Sterling UMC. The images are the sole property of Sterling UMC. If you do not want your child's image used, please check 'No."YesNo

Youth Permission Slip

Youth Connections Permission Slip

Student's Information

Student's Contact Information

Parents' Information

Medical Information

Student's Information

Student's Contact Information

Parents' Information

Medical Information

Verification

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