Virtual Permission Slip – Trinity Lutheran Church of Fort Pierce

Off Campus Event Permission Slip

Parent/Guardian Basic Information

Parent/Guardian Name(Required)

First Last

Date(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone(Required)

Email(Required)

Youth Basic Information

Youth Name(Required)

First Last

Date of Birth

Age(Required)

Please enter a number from 10 to 17.

Grade in School(Required)

Youth Address(Required)

Same as Parent/Guardian

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact

Name(Required)

First Last

Phone(Required)

Relationship with Youth(Required)

Medical Information

Physician's Name

First Last

Physician's Phone Number

Youth Allegies or Medications:(Required)

Important Info

Open Arms Address: 2015 S 13th Street, Fort Pierce, FL 34950 Departure Time: 7:45 AM Return Time: 6:30 PM **Staff and Chaperones should park in spaces next to shed.**

Things to Bring

1. Water Bottle 2. Lunch (If Not Buying at Zoo) 3. Sunblock 4. Spending Money (Gift Shop, Snacks, Lunch, Etc.) 5. Neck Pillow for Travel (Optional)

Rules

1. All youth must sign this form indicating their agreement to these rules. 2. No one is allowed to attend without a signed parental permission slip and contact numbers. 3. No insults or sarcasm: We do not put others down, make fun of others, pick on others, or gossip about others. 4. Use your body respectfully: No revealing clothing, no PDA, no chasing, throwing, or hurting others. 6. Keep it clean: no swearing 7. NO personal video games. 8. Special medication or required items should be indicated on the permission form and given to the chaperones. 9. All participants must respect othersʼ physical boundaries. 13. Be considerate and respectful of other participants and leaders.

Click here to indicate that you and your youth have read the rules.(Required)

Click to sign.

Medical and Liability Release(Required)

Click to sign.

The above named student has my consent to travel with this campus/organization. I understand that the student will be supervised while en route,
participating, and during unscheduled time and that normal precautions will be taken in the interest of safety and well being. I agree to release
Trinity Lutheran Church, its employees, and sponsors from all legal responsibility and liability on this trip.

Permission is granted for my child to receive medical care if:
(1) such care is deemed necessary by the persons in charge of the event;
(2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-
being of the child affected;
(3) I cannot be personally contacted.

I further agree not to hold Trinity Lutheran Church or any of its paid staff or volunteers responsible for any accident
that may occur on the way to, from, or during the event. I indemnify, defend and hold harmless Trinity Lutheran
Church for all claims made and liabilities assessed against them as a result of any event or activity. I release Trinity
Lutheran Church and all medical providers from liability in acting on my behalf in this regard and rendering such
medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.
Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be
necessary that my child be returned home due to disciplinary action, I will be contacted by the leaders and will be
responsible to pick my child up.

***By clicking above, I am acknowledging that I have read through and understand the above statements.***

My Child Needs Financial Assistance

Click to Sign

Trinity Lutheran Church believes that no child should be excluded for financial reasons and is happy to offer support when necessary. If your child needs assistance for this trip, please click the button above.

Date(Required)

38903