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YBL Parent Permission Form 2025
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Student First Name:
Student Name
Student Last Name:
Parent Name:
Parent Phone:
Drop-off and Pick-up
Check-in is at 1:00 PM on Monday, June 9, 2025, for first-year YBL students. Leadership Fellows will check in at 3:00 PM on Sunday, June 8, 2025.
At 2:00 PM on Wednesday, June 18, there will be a student showcase presentation followed by a sending service that you (and other adults who have permission to pick up your child) are invited to attend; check-out is at 5:00 PM.
Concerning the 2025 Youth Becoming Leaders institute, the following adults are authorized for drop-off and pick-up (the adult who picks up your child will need to provide his or her driver's license as a means of identification):
Health Information
Describe any allergies:
Describe any medications:
Describe any special needs and/or restrictions:
Insurance Company:
Policy Number:
Emergency Contact Information
Please provide parent/guardian information in case of an emergency, as well as someone we should contact if a parent/guardian is unavailable.
Are you an Emergency Contact for this student for this event?
Are you an Emergency Contact for this student for this event?
Yes
No
Emergency Contact 1 (Parent or Legal Guardian) Full Name:
Emergency Contact 1 (Parent or Legal Guardian) Phone Number:
Emergency Contact 1 (Parent or Legal Guardian) Full Name:
Emergency Contact 1 (Parent or Legal Guardian) Phone Number:
Emergency Contact 2 (Parent or Legal Guardian) Phone Number:
Emergency Contact 2 (Parent or Legal Guardian) Full Name:
Additional Emergency Contact Full Name:
Additional Emergency Contact Phone Number:
Assessment
I agree to my child’s participation in the assessment process associated with the Youth Becoming Leaders program. I understand that the information provided will be anonymous and unable to be linked to his or her identity and that there are no likely risks associated with this assessment process.
I agree to my child’s participation in the assessment process associated with the Youth Becoming Leaders program. I understand that the information provided will be anonymous and unable to be linked to his or her identity and that there are no likely risks associated with this assessment process.
Yes
No
Permission to Use Photographs or Video Recordings
I give Asbury University permission to use photographic portraits, pictures, digital images, video and names. They may be included in whole or in part for any lawful purpose, including but not limited to any University publication, website, promotion or news about the event.
I give Asbury University permission to use photographic portraits, pictures, digital images, video and names. They may be included in whole or in part for any lawful purpose, including but not limited to any University publication, website, promotion or news about the event.
Yes
No
I hereby authorize the directors of Youth Becoming Leaders to act for me according to their best judgment in any emergency requiring medical attention. Additionally, I hereby waive and release Asbury University and the Youth Becoming Leaders directors and their employees from any and all liability for injuries incurred while at camp or arising out of my travel to and from the camp.
Typing your name into this text box serves as the equivalent or signing this document and indicates your agreement to all of the above statements.
Parent/Legal Guardian Signature:
Submit