Friday Night Live for middle school youth!

Child's Full Name *

Birthday M/D/Y *

Ages *

10
11
12
13

Grade *

5th
6th
7th
8th

School Name *

Will your child walk home? *

Yes
No

If not, who will pick your child up?

Full Name of Parent(s) or Legal Guardian(s) *

Full Address *

Mobile Phone *

Email *

Health Insurance Co.

Policy #

Medical Doctor

Phone #

Name 1 *

Phone # *

Name 2 *

Phone # *

Agreement *

I accept the agreement terms below

By checking this box, you are agreeing that you are the parent/guardian of the child listed above who is under 18 years of age. You have read the above info, the Permission/Waiver and are fully familiar with the contents thereof. You give permission for your child named above to participate in Friday Night Live at Oxford Circle Mennonite Church. In consideration for allowing the participation of your child in the activities of Oxford Circle Mennonite Church, you hereby consent to the Permission/Waiver Form, including the Release of Liability, on behalf of your child, and agree that this Permission/Waiver Form shall be binding upon you. You also give permission for videos/photos of your child named above to be used for promotional purposes and to receive information from this program by text and/or email.

A PLACE OF HOPE AND HEALING