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(print this and have your parent or guardian sign it!)

Name of Participant (youth): ________________________________________

Parent/Guardian’s name: ___________________________________________


Event name: _____________________________________

Approximate Event Start Time and Date: _________________________________

Approximate Event End Time and Date: _________________________________



In signing this form, I hereby give permission for my child  whose name is above to participate in the event described above.   I also grant permission for my son/daughter to be transported in privately owned or rented vehicles.  Further, I will not hold staff nor youth leaders of Hopewell Presbyterian Church, nor any of its representatives or Trustees responsible for any damages or injuries sustained during the course of activities for the above dates and times.

In case of a medical emergency, I understand that every effort will be made to contact the parent/guardian of the young person.   In the event that I cannot be reached, I hereby give permission to the physician selected by the staff or person designated by the staff to give medical attention to my child, as named herein.

Family Health Insurance Company: ____________________________________

Policy Number: ___________________________________________________

Telephone #’s where I can be reached: _________________________________

Signature of Parent/Guardian: _______________________________________

Any medical or other health-related problems we should be aware of:

Note: We must have a permission slip for each person attending this event.  If you do not have your permission slip, you will not be permitted to attend.  Sorry, but we have to be sure you have permission and the needed medical data in case of an emergency.  Thanks!

Another Note:  Unless you are a leader, you must have this signed by a parent.

Questions?   Call Chris Kile at 609-466-0758 (church) or 609-466-6444.