Event Permission Agreement TEMPLATE

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This form cannot be submitted until an administrator completes the setup process to receive online payments.

Permission Information

Name of Child/Youth

Child/Youth Phone

Name of Parent/Guardian(s)

Parent/Guardian #1 Phone

Parent/Guardian #2 Phone:

Payment

Health Information

Have you already submitted your child's health information for this program year? YES. Skip this section and move to NO. Please complete each entry listed here.

By completing this form, I am agreeing that in case of an emergency, Hunt's Memorial UMC leaders have my permission for my child to receive medical treatment.

Name of Insurance Carrier:

Policy Number:

Is your child taking medication? Yes No

If yes, please specify:

Is your child allergic to anything? Yes No

If yes, please specify:

Emergency Contacts

Name (contact #1)

Relationship (contact #1)

Phone (contact #1)

Name (contact #2)

Relationship (contact #2)

Phone (contact #2)

Name (contact #3)

Relationship (contact #3)

Phone (contact #3)

Sign

By completing this digital form and typing my name below, I am a) giving permission for my child to attend the above described event, b) acknowledging and accepting the risk of property damage, personal injury and any and all other damages of any kind or nature associated with my child's participation in such event, c) accepting personal financial responsibility for any such damage or injury, and d) agreeing to hold Hunt's Memorial UMC, its affiliates and its representatives harmless from any and all claims, demands, costs, expenses, liabilities, judgments, sums of money, actions, and causes of action of whatever kind and nature associated with my child's participation in such event, including, without limitation, those predicated upon negligence.

Type full name here to "sign" this permission form:

Date Completed

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

EVENT INFORMATION:
Name of Event:
Date(s):
Start Time:
End Time:
Location:
Cost:
Transportation:
Notes:
Please complete this permission slip by:

Event Permission Agreement TEMPLATE

Description

Please Fix the Following