St. Paul's Episcopal Church - Salem, OR: Children's Ministries: St. Paul's Annual Permission Form

Please fill out the form below. If you have any questions, please contact our office at 503-362-3661.

* Required

Errors

Name of Youth *

Address Line 1 *

Address Line 2

City *

State *

ZIP Code *

Date of Birth *

Youth Phone Number *
( ) - ext.

Youth Mobile Phone Number *
( ) - ext.

Name of Parent / Guardian *

Relationship to Youth *

Parent / Guardian Phone Number *
( ) - ext.

Parent / Guardian Email Address *

Emergency Contact #1

Emergency Contact Name *

Emergency Contact Phone Number *
( ) - ext.

Relationship to Youth *

Emergency Contact #2

Emergency Contact #2 Name *

Emergency Contact #2 Phone Number *
( ) - ext.

Relationship to Youth *

Permission for Emergency Medical Treatment: In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact. If no contact can be made, I hereby give authorization to St. Paul's Episcopal Church to seek treatment for my child and/or dependent minor by a licensed physician pursuant to Oregon law. I know of no reason(s) why my child/dependent may not participate in prescribed activities except as noted on the Health History Form. If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions and send to stpauls@stpaulsoregon.org *

Yes

No

Liability Waiver: I understand that all reasonable safety precautions will be taken at all times by the church and its paid and volunteer staff during all youth events. I understand the possibility of unforeseen hazards and know of the inherent possibility of risk. I agree not to hold the church, its leaders, employees, or volunteer staff liable for damages, losses, diseases, or injuries incurred by my minor child, as named herein. *

Yes

No

Permission for Trips: My child has permission to travel to, attend and participate in church-sponsored activities that are 1) located within one hour's driving time of the regular meeting place, 2) not exceeding 6 hours, and 3) not considered high risk activities. *

Yes

No

Permission to Use Photographs: I hereby consent that the videos, photographs, motion pictures, electronic images and/or audio recordings of my child may be used by St. Paul's Episcopal Church for publicity purposes. I understand that the last name and residence will not be used for publicity purposes. *

Yes

No

Special Accommodations: My child requires the following special accommodations (write "none" if there are none): *

Parent Agreement: I have read and understand this Annual Parent Permission Form. I may change or revoke any aspect of this agreement at any time by submitting my request, in writing, to the church office or youth group leader.

First Name *

Last Name *

Please select today's date *