Youth & Kids Permission Slip

Thank you for allowing your child to attend events at Clare Assembly! At Clare Assembly, safety is our top priority. Please note: all information provided in this permission slip is password protected. Drivers of events will be given printed-off permission slips in case of an emergency.

Questions for Parents/Guardians

Name of Child (or Children) *

Tip: Please enter the names of the children you are giving permission for, separated by commas. Please include first and last names.

I ________________, give permission for my child (or children) to attend and/or be transported via church van to all Clare Assembly events for the current year. *

Tip: Please enter YOUR first and last name.

The current year is ____________________________ *

The permission slip is for: *

Ember Youth (6th-12th grade)

Kindle Kids (K-5th grade)

I hereby give permission for any and all medical attention to be administered to my child in the event of accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below.

Permission

Yes

Parent First Name *

Parent Last Name *

Home Address

Home City

Home State

Home Zip Code

Phone Number *

Email Address *

Insurance Company *

Policy Number

In case I cannot be reached, any representative of Clare Assembly of God's Youth and Kids Leadership Team is designated to act on my behalf.

Designation

Yes

Known Allergies

Physicain

Physician phone

Physician address

Would you like to receive text and email updates on future Youth and Kids events?

Yes for Youth

Yes for Kids

Yes, only email

Already signed up

Signature of parent/guardian

Date