Permission Slips

Permission Form

Student's Name*
First Last
Email Address*
Phone*
DOB*
MM slash DD slash YYYY
Grade*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
This consent form covers all The River Church of the Nazarene, Inc. activities from: Jan. 1st – Dec. 31st 2021 including transportation in the church van to and from church.
Signing hereby releases The River Church of the Nazarene, Inc. and the directors and/or volunteers thereof from any responsibilities and liability for injury or loss occurring while participating in all activities sponsored by the church and assumes all risk in the use and enjoyment of said activity.
Date*
MM slash DD slash YYYY
Parents/Legal Guardian*
I hereby authorize an adult to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by The River Church of the Nazarene, Inc.
Date*
MM slash DD slash YYYY
Parents/Legal Guardian*
Is your child presently taking any medicine, prescription or over the counter? If so, please list.
Is your child allergic to any medications (including anesthetics)? Does your child have ANY allergies? If so, please list.
Is there anything else you feel we need to know about your child?
Emergency Contact*
First Last
Phone*
Emergency Contact
First Last
Phone
Name
This field is for validation purposes and should be left unchanged.

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