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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 June 1, 2022 through August 31, 2023.

First Participant's Name

First Name*

Last Name*
First Participant's 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*
Second Participant's 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*
Third Participant's 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*
Fourth Participant's 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*
Fifth Participant's 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*
Sixth Participant's 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*
Seventh Participant's 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*
Eighth Participant's 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*
Ninth Participant's 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*
Tenth Participant's 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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's 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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