PRAISE ASSEMBLY OF GOD, DERBY KS
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YouTube Channel ROP Kansas
Parental Permission and Consent Form
*
Indicates required field
Name of Student
*
First
Last
Student's Birth Month
*
January
Febuary
March
April
May
June
July
August
September
October
November
December
Students Date of Birth
Day
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Name of Parent/Guardian
*
First
Last
Agreement
*
I Agree that I am the legal guardian of said minor(s).
Event Name
*
Ex: Youth Convention Lock-In
Start Date/Time
*
Ex: 9/23/15 2PM
End Date/Time
*
Ex: 9/23/15 2pm
Choose Any
*
As legal Guardian of said minor i here by give permission for activity or event.
Please note the reasoning we ask for such information is for students safety and to maintain easily accessible communication with said parent(s)/guardian(s). Thank you for your patience and time!
Phone Number
*
Emergency Contact
*
First
Last
Emergency Contact #
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Allergies Drug/Food
*
Asthma
*
Yes
No
Diabetes
*
Yes
No
Last Tetanus
*
month/day/year
Agreement
*
As legal guardian i here by consent to any hospital, medical, or surgical care and treatment, and administration of anesthesia. (determined by a qualified physician to be necessary for the welfare of said minor).
Submit
Home
About
>
What We Beleive
When We Meet.
Place of Prayer
Contact
Resorces
YouTube Channel ROP Kansas