Page Updated Monday, October 11, 2010

Youth Permission Form

If you plan to attend any youth event, we need each participant to fill out this form prior to the event.

You can either Download and Print the form, or you can fill out the online form below.

Permission Form

Asterisk (*) indicates a required field.

Participant's First Name: *
Participant's Middle Initial: *
Participant's Last Name: *
Address 1: *
Address 2:
City: * State: * Zip: *

I am giving approval for my student to participate in: *


Special Considerations or Restrictions: *
Hold Harmless Agreement

I understand that participation in the activity involves a certain degree of risk. I have carefully considered the risk involved and have given consent for myself or my child to participate in the activity. I understand that participation in the activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release His Place Fellowship, the Board of Elders, the activity coordinators, and all youth leaders, volunteers, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.

In case of emergency involving my child, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to the adult leader in charge to secure proper treatment.

Participant's Signature: * Date:

Parent/Guardian Signature: * Date:
Emergency Contact Name: *
Emergency Contact Phone Number (include area code): *
Email Address: *

By checking this box I agree to hold harmless agreement and give my child permission to attend event specified. *

Contact the Youth Leaders with Any Questions:

Jeremy and Tana Futrell
youth@hisplacefellowship.com
573-429-4424

 
 
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