CIRCLE J MEETS
WEDNESDAYS
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 2023 through July 2024.
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
PERMISSION 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 2023 through July 2024.
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))
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