Let's have fun!

THE ATTIC

Calvary Chapel Stroudsburg

2025 Youth Activity Permission Slip

(for Activities sponsored from January 1, 2025 – January 1, 2026)

Participant Information

Participant First Name

Participant Last Name

Birthdate

Gender

Grade

Participant Phone Number

Allergies:

Medications:

Physical handicaps or limitations

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Secondary Parent/Guardian First Name

Secondary Parent/Guardian Last Name

Phone Number

Family Physician

Phone Number

Name of Participant Insurance Company

Policy or Group Number

Participation Agreement

In consideration for the opportunity to participate in the activities sponsored by Calvary Chapel Stroudsburg for the above mentioned period of time, I, the parent/guardian of the above named participant(s), acknowledge and accept the risks of injury associated with participation in and transportation to and from the activities. I accept personal financial responsibility for any injury sustained during the activities or during transportation to and from the activities. Further, I promise to indemnify, defend, and hold harmless the activity sponsor or its agents, employees, volunteers, or any other representatives for injury or illness related directly or indirectly out of the described activities or transportation to and from the activities. In the event of an emergency, I hereby authorize an adult leader for any activity, as an agent for me, to consent to any x-ray examination, medical, dental or surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted as soon as possible. I, the undersigned, give permission for Calvary Chapel Stroudsburg to photograph and/or video record me during events and activities. I understand that these photos and videos may be used for promotional purposes, including but not limited to social media, website content, brochures, event flyers, and other materials related to the promotion of the youth ministry. I grant Calvary Chapel Stroudsburg and its authorized agents the right to edit, alter, publish, and distribute such materials in any media format now known or hereafter developed. I also understand that I will not receive any compensation for the use of these photos/videos, and I waive any right to inspect or approve the finished product that may be used for promotional purposes. By signing this release, I affirm that I am a legal adult or the parent/guardian of a minor participant. If under 18, a parent or guardian's signature is required below.

I agree to the above agreement.

Signature of Parent/Guardian

Today's Date

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