Children & Youth Activity Permission | St. Michael and All Angels CDM

Please complete the following form for each child participating in St. Michael and All Angels activities. Once completed, this form will be active for one year.

Children & Youth Activities Permission Form

Participant Information

* First Name:

* Last Name:

* Contact Phone:

* Address:

* Date of Birth (MM/DD/YYYY):

* Current Age:

Parental Information

* First Name (parent 1):

* Last Name (parent 1):

* Phone (parent 1):

* Email:

Address if different from child:

First Name (parent 2):

Last Name (parent 2):

Phone:

Email:

Address if different from child:

Additional Guardian Information (if applicable)

First Name (additional guardian):

Last Name (additional guardian):

Relationship to Child:

Phone:

Email:

IN CASE OF EMERGENCY:

Saint Michael and All Angels Episcopal Church makes every effort to provide a safe and secure environment for your child during our event. In order to better protect the safety and health of your child, we request that you provide the following information:

In case of an emergency, Saint Michael and All Angels Episcopal Church will contact the parent(s) listed above.We request that you provide another contact (not living at the same address) who is authorized by you to act on your behalf should you not be available.

Emergency Contact

* Emergency Contact First Name:

* Emergency Contact Last Name:

Emergency Contact Phone:

Email:

Permission Notice

I give my consent that the minor named below

* Child's First Name:

* Child's Last Name:

has permission to participate in Saint Michael and All Angels Episcopal Church, Corona del Mar related activities, both on church property and church sponsored events off-site for one (1) year from this date:

* Date (MM/DD/YYYY):

I grant permission to Saint Michael and All Angels Episcopal Church, Corona del Mar, CA, its agents, employees and its designated volunteers the irrevocable and unrestricted right to produce photographs, audio and video recordings of my child, myself, and members of my family while at Saint Michael and All Angels Episcopal Church, Corona del Mar, CA, or any off-site church-sponsored event for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium. I hereby release Saint Michael and All Angels Episcopal Church, Corona del Mar, CA and its legal representatives from liability for any violation or claims relating to said images or video. Furthermore, I grant permission to use the statements of my child, myself, or my family members given during an interview or for the purpose of advertising and publicity without restriction to time limit or geographic area. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.

I agree to the above Consent and Photo & Media Release statements

I consent to sharing the above information in accordance with the privacy policy

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