Darby Creek Church Annual Youth Permission Form

Darby Creek Church - Annual Youth Permission Form
Part 1 - Parent / Guardian Information
Name of Parent / Legal Guardian (person filling out this form): *

First Name Last Name
Parent / Legal Guardian Address (person filling out this form) *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent / Legal Guardian Phone or Cell # (person filling out this form) *

Area Code Phone Number
Parent / Legal Guardian Email (person filling out this form)
If you provide your email address, we will email you a copy of your completed form
I am the student's *

Mother Father Legal Guardian
Parent's Information
Father's Name

First Name Last Name
Father's Cell #

Area Code Phone Number
Father's Email
example@example.com
Mother's Name

First Name Last Name
Mother's Cell #

Area Code Phone Number
Mother's Email
example@example.com

Part 2 - Student Information
Full Name of Student 1 *
Email
example@example.com
Phone Number

Area Code Phone Number
School
Grade
Health Insurance Carrier
Health Insurance Policy #
Date of Birth

Month Day Year
Date
Current Medications
Allergies
Any special medical instructions
You can enter up to three students on this form, do you want to enter another student’s information? *

Yes No

Part 2b - Student Information
Full Name of Student 2
Email
example@example.com
Phone Number

Area Code Phone Number
School
Grade
Health Insurance Carrier
Health Insurance Policy #
Date of Birth

Month Day Year
Date
Current Medications
Allergies
Any special medical instructions
You can enter up to three students on this form, do you want to enter another student’s information? *

Yes No

Part 3 - Photo / Video Release
Please note, you MUST check either the "Opt In" box OR the "Opt Out" box. Once you check one, the other will not be required.
Opt In *

I'm OK with it
I hereby, authorize Darby Creek Church (DCC), to publish the photographs and/or videos taken of any minor children and their names who have been stated on this form , for use but not limited to DCC printed publications, website or social media.

I give permission to DCC to copyright, use and publish the photographs and/or videos of my child(ren) with or without names for any lawful purpose, including illustrations, advertising and web content, social media posts, etc.

I release, all claims against DCC with respect to ownership and publication including any claims of compensation. I confirm that I am the parent or legal guardian of the minor child(ren) and have the authority to authorize to use their photographs and names.
Opt Out *

No thank you.
I do not want any photos or videos of my child(ren) to be used in any church publication, website, social media, or in any other way.

All students named on this form have the permission of the undersigned to participate in Darby Creek Church events where he/she is driven in a vehicle by someone other than his/her own parent or guardian. This form is effective from September 1, 2019 through August 31, 2020.

In the event of an emergency affecting the health or welfare of this participant, the sponsors, leaders, or adult chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be borne by the participant, orparents / guardians of the participant.
Parent / Legal Guardian Signature *

Sign your name with your mouse / touchpad or with your finger if you have a touch screen. Clear
After pressing the SUBMIT button below, please wait 15 to 20 seconds and you will be taken to a "Thank You" screen confirming your form was submtted.
Should be Empty:

Darby Creek Church - Annual Youth Permission Form