Permission Form

GRACE POINT COMMUNITY CHURCH STUDENT MINISTRIES

 UNIVERSAL PERMISSION AND RELEASE FORM

Effective Date: ___________________________

Minor's Name:_____________________________________________________________

Minor's date of birth:_______________________

Parent or Legal Guardian name: _____________________________________________________

Address_____________________________________________________________________

Home Phone: _______________________________

Parent Work #: _______________________________

Parent Cell #: ________________________________

Parent E-mail address: __________________________________________________

Emergency contact name and phone #: _________________________________________________

Medical notes/allergies: ____________________________________________________________________________________________________________________________________________________________

Family Physician: _________________________________________ Office #: _______________________

As a parent/legal guardian, I do, herewith, authorize for the named minor to receive treatment by a qualified and licensed medical doctor in the event of a medical emergency.

My child has my permission to participate in all activities with Grace Point Community Church Student Ministries. As a parent/legal guardian, I do, herewith, release the Grace Point Community Church, and/or its agents, of any liability in the event of accident, or mishap resulting in the injury of the named minor.

Signed: ________________________________________ Date:______________________

                            (Parent or Legal Guardian)

As a parent/legal guardian, I give my permission to Grace Point Community Church Student Ministries to use my child's picture on the website.

Signed: ________________________________________ Date:______________________

                                   (Parent or Legal Guardian)

www.gracepointchurch.org