Confirmation Permission Slip 2024-2025

I, the Parent/Guardian of: (enter child's name below)

Child's Name

Birthdate

Grade

7th 8th

Hereby give my approval to his/her participation in any and all activities of Fox Point Lutheran Church during the period of September 1, 2024 through August 31, 2025. I assume all risks and hazards incidental to such participation, including transportation to and from activities. I do hereby waive, release, absolve, and indemnify the church, its servants, and participants, as well as transporting the above named child to and from related activities, for any injury or action resulting in a medical claim. I also give the physician/hospital selected by the program supervisor permission to secure proper treatment for my child, should it become necessary. I also assume responsibility of all medical expenses incurred. Should it be necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Primary Parent/Guardian First and Last Name

Mobile Phone

This address will receive a confirmation email

Parent/Guardian #2 Name

Mobile Phone

Emergency Contact Person OTHER THAN PARENT (first and last name)

Emergency Mobile Phone

Relation to Child

Insurance

Insurance Company:

Policy Number

Insurance ID Number:

Physician’s Name

Physician’s Phone Number

Known Allergies

Special Medical Conditions

Medications - include instructions/dosages

Date of Last Tetanus Shot

Today's Date

Do you approve the Approval

approve

Approval

Parent/Guardian Signature (enter Parent's first and last name)

Description

This information will be kept on file for the 2024-2025 school year. Let us know if any of your information changes.

Also, please note that a new permission slip is needed for each year that a student participates in Confirmation. If you'd rather fill out a physical copy, i.e., a PDF print out, click here to go directly to our Printable Permission Slip.

If you'd rather fill out a downloadable PDF (physical) copy, go to https://foxpointchurch.org/youth-middle-school/ and scroll down to "Resources" > Forms (Downloadable) > and select which form.

You can send your completed form to the church office or email a scanned version to lori@foxpointchurch.org.

Confirmation Permission Slip 2024-2025

Description

Please Fix the Following