CIRCLE J APPLICATION

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Dear Parents:



The Circle J Kids Club is planning trips and other activities which will necessitate taking your child off the church grounds.  All such activities will be under supervision of adult sponsor(s).  We need your permission to take your child off the church property. This permit slip will give us a record, which will be in effect for the period of  August 2017 through July 2018.



Sincerely,

The Volunteer Staff of the Children's Ministry Teams and Department
of the Board of Christian Education at First Baptist Church of Clay Center, KS



PERMIT SLIP




I give permission for ____________________________________to leave the church grounds to go on a supervised activity with adult sponsor(s).  This permit will be kept on file at the church office and is valid. August 2017  through July 2018.



MEDICAL INFORMATION




Address: __________________________City:_____________State:_____Zip_______




Home Phone Number ____________________Work Phone Number ______________



Cell #1_________belongs to___________/Cell #2_________belongs to ____________



Email Address___________________________________________________________



Insurance Company: ___________________________Policy Number_____________



Name of Policy Carrier:_____________________



Primary Physician:_________________________Office Phone Number___________



Any special medical needs (allergies, food, etc.)___________________





Person to Notify in Case of Emergency_______________________________________



Home Telephone:________________________Work Phone Number______________



In the event of an emergency, where medical treatment is required, I give my permission to the church staff or sponsor to obtain the services of a licensed physician.  Please attempt to notify me immediately.




I realize that any activity or trip has its risks of injury, however, I would like the above named child to participate.  I give up any claims for injuries, including death, my child might sustain and agree to hold harmless the First Baptist Church, its Board of Deacons, staff and/or volunteers.



By signing this permit slip, I agree to all the above statements.



DATE ________________            _________________________________________________________________


                                                                        (Parent or Guardian))



                                                                                            Over>







GRADE          _________      AGE   ___________  BIRTHDAY _________________

                                                                                                            month/   . day/     year

GRADE          _________      AGE   ___________  BIRTHDAY _________________

                                                                                                            month/   . day/     year





Parent(s) or Guardian (s) Name Printed ____________________________________
                                                                     ____________________________________






PEOPLE ALLOWED TO PICK UP CHILD



Name _______________________________   Relationship ______________________



Address_____________________________    Employer _________________________



Phone # _____________________________    Work # __________________________







Name _______________________________   Relationship ______________________



Address _____________________________   Employer ________________________



Phone # _____________________________   Work # __________________________









PEOPLE NOT ALLOWED TO PICK UP CHILD



Name _______________________________   Relationship ______________________



Name _______________________________   Relationship ______________________





OK to Walk Home (please circle one)            Yes          No