PARENT CONSENT
FORM
Participant Name____________________________
_______________________________ ______
(Last)
(First)
(M.I.)
Mailing
Address_________________________________________________________________________
City______________________________________ ST______ ZIP_______ Home Phone
(___)__________
Email
Address___________________________________________________________________________
Home
Church___________________________________________________________________________
City_____________________________________ ST___________
Emergency
Contact_____________________________________
Phone (____) _________
Leader who is responsible for
you:________________________________________________________
Mom’s Name____________________ Home Ph. (___)______ Work Ph. (___)______ Cell
Ph. (___)______
Dad’s
Name_____________________ Home Ph. (___)______ Work Ph. (___)______ Cell Ph.
(___)______
Guardian_______________________ Home Ph. (___) _____ Work Ph. (___) ______
Cell Ph. (___)______
FOR PARENTS OF PARTICIPANTS:
It is our objective and commitment to treat each participant as an individual
and meet their specific needs. Any information you can share with us about your
child will help us meet this objective. For example, please specify personal
needs, medical concerns, behavioral observation and other relevant information.
A few insightful sentences will help us know your child and provide a healthy,
growing, Christian experience for them while they are participating.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
I, the undersigned parent/guardian of
___________________________ (“my child”), hereby consent to my said child’s
participation in the Heartland Christian Camp.
I
understand that photographs, images or audio tapes of my child may be taken
at this event. I hereby
give permission for the host of the event TO do so and use these images in
conjunction with promotion of like
events/programs without remuneration to me or my child. Participant’s
names, addresses, or other personal
information is not released in any publicity materials .
Authorization of guardian of participant (if
minor)
Date
__________________________
Signature_______________________________________________________
Printed
Name___________________________________________________
Relationship to
Participant________________________________________
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