Today's Date *

MM

DD

YYYY

Primary Parent/Guardian Name *

First Name

Last Name

Second Parent/Guardian Name (optional)

First Name

Last Name

Permission to publish pictures: *

I give Ridgewood Christian Reformed Church permission to publish pictures of my child/children at church sponsored events on social media, on our website and on printed documents. (Ridgewood will not publish any information about your child online such as their name in conjunction with their picture.)

I do not give permission.

Permission to transport your child/children: *

I give permission for my child/children to participate in Ridgewood Christian Reformed Church youth group activities and to be driven by the adults in charge when necessary.

I do not give permission.

Permission to provide medical care:

Should my child require immediate or emergency medical care while engaged in an activity sponsored by the Ridgewood Christian Reformed Church, in my absence, I hereby grant the Church authority to release my child for medical treatment to such medical personnel as the Church determines appropriate under the circumstances.

I do not give permission.

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Any Allergies *

Yes (please explain below)

No