Pleasant Grove Piney Baptist Church Youth Trip / Activities Permission Form
Child's Full Name
*
First Name
Last Name
By checking below you give permission for your child to attend the following activity :
Cades Cove, Meal, and hike to Abraham Falls
Price (please send money in a sealed envelope marked with activity.)
Departure/Return Site
Date of Trip
Departure Time
Return Time
Mode of Transportation
Purpose of Trip
Food, fun and fellowship
Specific Activities Planned
Travel to picnic area, then to Cades Cove Baptist Church for devotion and some singing, then on to Abram Falls for hike
1
I, the parent/guardian of the student named above, hereby give permission for my child to take part in the trip described above. I understand that the following conditions apply:
2
a. I understand that I am responsible for getting my child to and from the departure and return sites identified above. I understand that my child shall be accompanied by staff member(s) during the trip, including while traveling from the departure site to the destination site, and from the destination site to the return site.
3
b. I understand that my child is expected to behave responsibly and to follow the Christian conduct and values..
4
c. I agree and understand that I am responsible for the actions of my child, and I release the PGPBC from all claims and liabilities that arise in connection with the trip, except if due to the negligence of church officials.
d. I confirm that my child is medically fit and able to participate in all activities described above, except for the following activities: (please write "Yes" to confirm)
*
e. I have indicated below any permanent or temporary medical or other condition(s) including special dietary and medication needs, or the need for visual or auditory aids, which should be known about my child: (please write "N/A" if this does not apply to your child)
*
5
f. I understand that as a parent, if I believe it is necessary to limit my child’s activity to a great extent, then the PGPBC may not be able to accommodate my child on this trip and that I and my child will be informed of this decision as soon as possible upon the receipt by PGPBC of this completed consent form.
6
g. I agree that in the event of an emergency injury or illness, the staff member(s) in charge of the trip may act on my behalf and at my expense in obtaining medical treatment for my child.
7
h. I understand that alcoholic beverages and/or illegal drugs are prohibited and have discussed this prohibition with my child. I understand that if my child is found in possession of these substances, he/she will no longer be eligible for the trip and a parent will be required to pick up child.
8
i. I understand that students who violate Christian conduct may be excluded in the future by PGPBC from participating in other activities or trips..
Emergency Contact Name:
*
First Name
Last Name
Phone Number (1)
*
-
Area Code
Phone Number
Phone Number (2)
-
Area Code
Phone Number
Additional Contact
*
First Name
Last Name
Phone Number (1)
*
-
Area Code
Phone Number
Phone Number (2)
-
Area Code
Phone Number
E-mail
Insurance Company
Insurance Group # / ID #
Upload copy of Insurance Card if available
Upload a File
Cancel
of
or take a picture of the insurance card for our records.
Are you interested in joining us as a chaperone? (We are limited to only a few chaperones per trip so we will confirm with you once we receive responses. Also, please note that chaperones will be responsible for paying all trip fees).
*
Yes
No
Signature of Parent/Guardian
*
Use mouse, stylus or finger to enter signature depending on your device!!
Printed Name of Parent/Guardian
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Enter the message as it's shown
*
Submit
Should be Empty: