YBL Parent Permission Form

Student Name

Parent Name:

Parent Phone:

Drop-off and Pick-up

Check-in is at 1:00 PM on Monday, June 5, 2022.

At 2:00 PM on Friday, June 16, 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 2023 Youth Becoming Leaders camp, 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?

Yes

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) Full Name:

Emergency Contact 2 (Parent or Legal Guardian) Phone Number:

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 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.

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.

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: