Youth Permission Slip 2023-2024

Name of participant*:

Grade as of Fall 2023 *

Address: *

Birthdate:

Student Phone #:

Student Email:

Name of Parent/Guardian 1: *

Contact Phone # (Parent /Guardian 1) *

Email (Parent/Guardian 1):

I would like to subscribe to VASSAR BAPTIST YOUTH CONNECTION weekly email:

Yes

No

Name of Parent/Guardian 2:

Contact Phone # (Parent/Guardian 2):

Email (Parent/Guardian 2):

I would like to subscribe to VASSAR BAPTIST YOUTH CONNECTION weekly email:

YES

NO

List Medical / Allergy Concerns*

Alternate Contact Person & Phone #

Hospital Insurance: *

YES

NO

Insurance Company and policy #: *

I represent and promise the student identified above has my permission to attend Vassar Baptist Church's youth events and participate in all activities for the 2023-2024 school year. SELECT "YES" IF YOU AGREE . *

YES

NO

I authorize the adult agents of Vassar Baptist Church, should the situation arise, to administer routine first aid and/or seek emergency medical treatment for my student, listed above. SELECT "YES" BELOW IF YOU AGREE. *

YES

NO

I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to release, forever discharge and hold harmless Vassar Baptist Church, its leaders, employees and volunteer staff from any & all liability and claims for damages, losses, sickness, or injury incurred by this student. I certify the above student has my permission to attend Vassar Baptist Youth Ministry events and participate in all activities. I also understand and permit that my student's picture and/or testimony may be used in the promotion of this ministry. SELECT "YES" IF YOU AGREE. *

YES

NO

VASSAR BAPTIST YOUTH RELEASE FORM AUG 2023- AUG 2024 SCHOOL YEAR