Christ Church Permission Form

Please complete the form below for your child or youth for event participation.

Please note that this document expires on January 31st each year, and needs to be renewed beginning on January 1st each year.

Participant Name *
Participant Name
Participant Date of Birth *
Participant Date of Birth
Participant Sex *
Participant Home Address *
Participant Home Address
Participant Phone *
Participant Phone
If none, enter "None." PRESCRIBED MEDICATIONS must be in original pharmacy container with the correct name, date, instructions, and physician's name on the label. The event staff will keep and distribute all medications during the event.
Parent/Guardian Name 1 *
Parent/Guardian Name 1
Parent/Guardian Name 2
Parent/Guardian Name 2
If none, state "None"
Phone 1 *
Phone 1
Phone 2
Phone 2
Phone 3
Phone 3
Non-Parental Emergency Contact *
Non-Parental Emergency Contact
Non-Parental Emergency Phone *
Non-Parental Emergency Phone
Physician's Name *
Physician's Name
Please notify the event staff is this participant has BEEN EXPOSED TO ANY COMMUNICABLE DISEASE within the three weeks prior to this event. Participants will NOT be allowed to attend if they arrive at the event ill.
Physician's Phone *
Physician's Phone
I.e. Tylenol, Advil, Kaopectate, etc.
If none, enter "None"
If none, enter "None"
If none, enter "None"
If none, enter "None"
I hereby ________ permission for Christ Church to use pictures of my child within Christ Church, the Diocese and internal communications. *
EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. *
TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT (21+) chaperone in accordance with Safeguarding God's Children policies while attending and participating in activities sponsored by Christ Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. *
CONTRABAND: Nowhere and at no time during youth events shall youth possess or use firearms, illicit drugs and/or paraphernalia (including lighters), alcohol, or tobacco. *
QUARTERS: Never shall a male enter a female's quarters or a female enter a male's quarters. We at Christ Church like for everyone to have a good time, and this is part of that: we protect our children. Boys=Blue, Girls=Pink, No Purpling! There will also be cause for disciplinary action if youth are caught in intimate relations, even if not in quarters. This is a mandatory parent notification. *
CONFIDENTIALITY: All of the details and information of this agreement are confidential and shall only be used by Christ Church and Diocesan Staff (the latter for Diocesan events only). Your completion of this form is the legal equivalent of your signature that you have read and understand all of the information provided and consent to your selections. *
By clicking the submit button, I understand I am submitting this Permission Slip. Please choose "I accept the digital signature" to digitally sign this submission or "I do not accept the digital signature," in which case we will have a paper copy of your submission for you to sign.
Digital Signers Name *
Digital Signers Name
This must be the parent/guardian listed earlier in the document.