PERMISSION TO PARTICIPATE AND MEDICAL CONSENT
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Parent’s or Legal Guardian’s Names
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Address
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Phone
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Email
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This address will receive a confirmation email
Church Regularly Attended
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Child's Name
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Date of Birth
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If Not Available In An Emergency, Notify
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Phone
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DOES YOUR CHILD HAVE ANY ALLERGIES, MEDICAL, OR OTHER HEALTH PROBLEMS OR TAKING ANY MEDICATIONS THAT WE NEED TO KNOW ABOUT OR WOULD HAVE AN EFFECT ON YOUR CHILD’S PARTICIPATION IN ACTIVITIES? IF YES, PLEASE SPECIFY:
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Signature of Parent or Guardian (Type Name or Names)
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Date of Signature
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Description
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