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Youth Activity Permission Form

and

Youth Contact Information
Pleasant Hill Presbyterian Church
3700 Pleasant Hill Road
Duluth, GA 30096
770-497-0233

I, parent or legal guardian of minor(s), do hereby give my express permission for my child to travel to youth activities sponsored by Pleasant Hill Presbyterian Church. I fully understand that my child may be riding with a church leader or parent volunteer of Pleasant Hill. I hereby release Pleasant Hill Presbyterian Church, its staff, employees and volunteer leaders and partners from any and all liability or from any and all claims, demands, or causes of action related to injuries sustained by my child during the authorized activity or event, including travel to and from the activity.

The permission is granted from August 25, 2024 through August 31, 2025.

First Participant's Name
First Name*
Last Name*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive the "Youth News" weekly e-newsletter
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Relationship*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Youth Grade and School
Youth T-Shirt Size
Youth Phone Number
Youth E-mail address
Parent(s) or Guardian's Name(s)
Parent(s) or Guardian's Cell Phone Numbers
Parent(s)/Guardian's E-mail Address
Adult Emergency Contact Name
Adult Emergency Contact Phone Numner
Adult Emergency Contact Relationship to Youth Participant
Permission to use photo/video of youth participant in PHPC material, print or online.*
Yes
No
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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