Permission Release Form
Zion Hill Baptist Church Permission Release Form

Child's Name *

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Last
Child's Date of Birth *

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Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone *

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Parent/Guardian Contact Phone *

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Emergency Contact *

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Last
Emergency Contact Phone *

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Please type DATE, TIME, and PLACE of event you are giving permission for your son/daughter to attend. *
By indicating here "I agree" I hereby agree to allow my son/daughter to attend the event listed above with the youth of Zion Hill Baptist Church. *
 I Agree 
In consideration of the opportunity for my son/daughter to participate in the event above, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY Zion Hill Baptist Church, volunteers and employees from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my son/daughter's participation in the Program. *
 I Agree 
I hereby grant permission to any staff person or volunteer to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that attention is needed and I cannot be reached. *
 I Agree 
My son/daughter is covered under a medical insurance policy. *
 Yes 
 No, They are not covered under any medical insurance policy and I hereby assume all responsibility for any cost. 
Please provide insurance information here. *
If not covered under an insurance plan please enter "None".
I hereby grant permission for a staff person or adult volunteer to provide the following over-the-counter medications to my son/daughter if requested by my son/daughter (Check all that apply:) *
 Benadryl (diphenhydramine) 
 Advil (ibuprofen) 
 Sudafed (pseudoephedrine) 
 Neosporin (triple antibiotic cream) 
 Aleve (Naproxen) 
 Claritin (loratadine) 
 Pepto Bismol (bismuth subsalicylate) 
 NONE of the above 
List any other medical information concerning medication, allergies, illness, etc as well as any dietary restrictions here.
Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by Zion Hill Baptist Church. Participants may be "tagged" or named in these photos at times. Parents/guardians who do not wish their child(ren) to be photographed or filmed should so notify Zion Hill Baptist Church in writing. *
 I Understand and agree OR will so notify Zion Hill Baptist Church in writing. 
Typing my name here acts as my electronic signature of this form. By entering my name I affirm that I am the parent or legal guardian of the child listed above, that all of the information I have entered above is correct, and that I understand and agree with all conditions listed above. *

First

Last
Date Signed *

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Email
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