EmailMe Form - Spruce Pine UMC Youth Activity Permission Form

Spruce Pine UMC Youth Activity Permission Form

Youth Information
First and Last Name: *

Birthdate: *

Address: *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Phone Number:

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E-Mail:

Parent/Guardian Information
Names: *

Home Phone: *

###

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Cell Phone:

###

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Mother's Work:

###

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Father's Work:

###

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E-Mail:

Emergency Information
Emergency Contact Person (other than parent) *

Home Phone: *

###

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Alternate Phone:

###

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Name and phone # of physician in emergency: *

Health Concerns (allergies, medications, etc.

This permission form is valid for all SPUMC events during 2011.

As parent or guardian I give permission for my child to participate in the SPUMC Youth Group activities. I understand that these events will be chaperoned by adult volunteers and/or church staff member. I will make arrangements for timely transportation home after the given event ends. In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or medical facility selected by my child's advisor and/or group leader to secure proper treatment for my child as named above.

I hereby give permission to display photographs taken of my child during youth events:

Yes

Parent Signature: *

Date

YYYY

Check here if you, as a parent, are willing to help with future youth events

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