Youth's Name: Address: City: State: Zip Code: Grade: —Please choose an option—K123456789101112 Date of Birth: Phone Number:

We do many reminders and correspondence via email. Please include your current, valid email address. Parent's/guardian's email address is preferred since youth members sometimes forget to relay message(s) in a timely manner.

Email: Photographs I AuthorizeI do not Authorize Social Media I AuthorizeI Do Not Authorize Movies PGPG-13
Photos and videos will be carefully viewed before posted onto any social media platform.

This blank permission slip will be effective for the year. I will cover all events, games, parades, and field trips for the year. If medical information changes close to any of the activities, please send a note to the founder/owner, Mr. Cossar, to attach to the permission slip.

EMERGENCY CONSENT FOR TREATMENT

I hereby give those persons responsible the authority to sign the permission form in order to render treatment deemed necessary by a hospital emergency department or doctor, in case of injury or illness in my absence, to my minor son/daughter listed below.

ALLERGIES: Allergy 1: Allergy 2: Allergy 3:

MOST RECENT TETNUS SHOT:

CURRENT MEDICATION: Med 1: Med 2: Med 3:

Family Physician: Phone:

I give my child permission to participate in the youth group and I will NOT hold the youth group leader/director, helpers/chaperones responsible for any injuries which may occur. I have read the rules and agree to help my child uphold the statement signed above. I will pay for any damages made by my child and I will pay to have anything broken, repaired, and/or replaced.

I, , have read and understood, and agree; to the best of my ability, to obey the rules of youth group, to participate in the practices and performances listed, and to take full responsibility for my action. I agree to listen and respect the leader(s) and his/her helpers. [/acceptance] Parent's/Guardian's Signature:
Today's Date: