Kids Church Permission Slip

This permission slip must be filled out by or with the consent of the "Primary Guardian". The field "Your Name" is where to put the Primary Guardian's information.

Your name *

Email address *

General Information

Primary Guardian Relationship to Children

Address

Phone Number *

Household members

IMPORTANT: Include ALL children you are registering for Kids Church as well as any secondary adults in the household who are permitted to drop off and pick-up the children from Kids Church.

Additional Information

Bus Transportation? *

The Kids Church Bus picks up and drops off families with on-file permission slips in the designated area within Brookside ONLY. Please specify below if you would like your children to be picked up by the Kids Church Bus.

Restricted Pick-Up List

At Kids Church, we understand families come from all walks of life. Some families may have situations surrounding custody, foster children, or other circumstances limiting those who are allowed to pick-up and drop-off your children. Please use the space below to specify anyone who is NOT allowed to pick-up your child. Please provide any additional details following needed courses of action.

General Notes

General notes on the family - anything additional beyond medical notes.

Permission Granting - Electronic Signature

By my electronic signature below, give permission for my child(ren) identified above to attend Nehemiah Bible Church’s Kid’s Church Ministry. By my signature below, I give permission to travel by car, van or bus with volunteers of Kids Church. This would be for a field trip or transportation to and from the sites. I understand that only licensed and qualified personnel will operate any vehicle to and from the sites, and that there will be at least one staff member present at all times. I agree to release Kid's Church and its Volunteers from any claims of damages, demands or liabilities, which may arise as a result of my child's participation on these trips.

I authorize any representative of Kid's Church to seek medical attention for my child or children when immediate medical care is warranted by the circumstances and I cannot be reached, or if under the circumstances there is not time to attempt to reach me because of the nature of the injury or illness. I further authorize the health care professional selected by Kid's Church to provide the necessary care and treatment for my child.

I give Kid's Church staff permission to access my child's records including achievement scores and pupil progress reports. The records will remain in a secure and designated staff area. I understand these records are necessary for the Kid’s Church ministry to successfully complete its evaluations.

Electronic Signature (Required) *

Please input your first and last name signifying signed agreement to the permission granting as noted above.

Photo Release Signature (Optional)

By my electronic signature below, I give permission for photographs and videos of my child to be used in informational or promotional material related to Kid’s Church and/or Nehemiah Bible Church.

Photo Release Electronic Signature

Please input your first and last name signifying signed agreement to the permission granting as noted above.

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