Permission Release Form

• Child's Name*
  First Name

  Last Name
• Child's Date of Birth*
  MM

  /

  DD

  /

  YYYY
• Home Address
  Street Address

  Address Line 2

  City

  State / Province / Region

  Zip / Post Code

  Antigua and BarbudaBahamasBarbadosBelizeCanadaCosta RicaCubaDominicaDominican RepublicEl SalvadorGrenadaGuatemalaHaitiHondurasJamaicaMexicoNicaraguaPanamaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesTrinidad and TobagoUnited StatesArgentinaBoliviaBrazilChileColumbiaEcuadorGuyanaParaguayPeruSurinameUruguayVenezuelaAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandUkraineUnited KingdomVatican CityAfghanistanBahrainBangladeshBhutanBrunei DarussalamMyanmarCambodiaChinaEast TimorIndiaIndonesiaIranIraqIsraelJapanJordanKazakhstanNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLebanonMalaysiaMaldivesMongoliaNepalOmanPakistanPhilippinesQatarRussiaSaudi ArabiaSingaporeSri LankaSyriaTaiwanTajikistanThailandTurkeyTurkmenistanUnited Arab EmiratesUzbekistanVietnamYemenAustraliaFijiKiribatiMarshall IslandsMicronesiaNauruNew ZealandPalauPapua New GuineaSamoaSolomon IslandsTongaTuvaluVanuatuAlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauCôte d\'IvoireKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe

  Country
• Home Phone*
   

  (###)

  -

  ###

  -

  ####
• Contact Number for Parent/Guardian*
   

  (###)

  -

  ###

  -

  ####
• Emergency Contact:*
• Emergency Contact Number*
   

  (###)

  -

  ###

  -

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• In consideration of the wholesome recreational and learning experience in which my son/daughter will participate, I as parent or guardian of my son/daughter, do hereby agree to allow my son/daughter to accompany the youth ministry of Zion Hill Baptist Church to (date, time and place): *
• In consideration of the opportunity for my son/daughter to participate in the Program, I agree to RELEASE AND HOLD HARMLESS AND INDEMNIFY Zion Hill Baptist Church, volunteers and employees from any liability, claims, demands and causes of action arising out of or relating to any loss, damage or injury sustained in connection with or arising out of my son/daughter's participation in the Program.*
  I agree

  I do not agree
• I hereby grant permission to any staff person to obtain medical care from a licensed physician, hospital, or medical clinic for my son/daughter in the event that I cannot be reached.*
  I am covered by hospitalization and medical insurance under policy.

  I do not have medical coverage and assume responsibility for any cost.
• Please provide insurance information below.
• I hereby grant permission to any staff person to provide the following over-the-counter drugs to my son/daughter if requested by my son/daughter (Check all that apply:)*
  Tylenol

  Benadryl

  Advil

  Sudafed

  Midal

  Kaopectate

  Neosporin

  pepto bismol

  None of these
• ADD any other medical information concerning medication, allergies, illness, etc.
• ADD any dietary restrictions
• Date*
  MM

  /

  DD

  /

  YYYY
• Parents/guardians of participants are advised that photographs or videotape of participants may be used in publications, websites or other materials produced from time to time by Zion Hill Baptist Church (Participants would not be identified, however, without specific written consent.) Parents/guardians who do not wish their child(ren) to be photographed or filmed should so notify Zion Hill Baptist Church in writing. *
  First Name

  Last Name
• Your Email