Permission Slip Template printable pdf download

Pittsboro United Methodist Church

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Parental Permission and Medical Authorization Form 2013-2014

MISSION TRIP PARENTAL PERMISSION

Student Name: _______________________________________________________________________________

Birth date: ___________________ Current Grade: _________ School:________________________________

Student Cell # :___________________ Student Email: _______________________________________________

Student Social Media i.e. FB, Twitter, Instagram____________________________________________________

Parent Email: __________________________ Parent Home #______________Parent Cell#_________________

I give permission for my youth (named above) to attend the Youth Mission Trip to Lexington, SC. I further give permission for

my youth to be transported to and from the event by approved adult volunteer drivers authorized by Pittsboro United Methodist

Church as outlined in the Pittsboro United Methodist Safe Sanctuaries Policy. I also give permission for my youth to be

transported by drivers from other churches who will be attending the mission trip site during the same week we will be there.

Photo Release

I recognize that the PUMC uses photographs and video images of events in church publications including websites and

newsletters. I hereby grant permission for photo/video images of my youth to be taken and used for such purposes.

Activity Release

I further give permission for my youth to participate in all supervised activities except as noted:

__________________________________ ______________________________ _________

Signature of Parent or Legal Guardian

Printed Name of Parent or Guardian

Date

Emergency Contact Information

Names of person and telephone numbers to call in case of emergency

Name: ______________________________________ Relationship: ______________________

Home Phone: ________________________ Cell/ Alternate Phone : _______________________

Name: ______________________________________ Relationship: ______________________

Home Phone: ________________________ Cell/ Alternate Phone : _______________________

Pittsboro United Methodist Church

229 E. Main Street, Pittsboro, IN 46167

(317)-892-4784

Permission Slip Template