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Youth Convention Activity Permission Form
October 19-21, 2023
Location: Northview Church
3401 25th St S
Fargo, ND
Total cost: $115 must be turned in to New Life office by October 4. Meals are extra.
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Date of Birth
*
Your answer
Grade entering
*
Your answer
Parent/Guardian's Name
*
Your answer
Best phone number to be reached at.
*
Your answer
Optional second phone number (work, cell, etc.)
Your answer
Emergency Contact (other than above) Name and Relationship to child
*
Your answer
Emergency Contact Phone Number
*
Your answer
Optional Second Emergency Contact (other than above) Name and Relationship to child
Your answer
Optional Second Emergency Contact Phone Number
Your answer
MEDICAL INFORMATION: List any changes from the Yearly Medical Release form currently on record:
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Your answer
MEDIA RELEASE: Participant gives permission for photographs and videos taken of the Participant during the activities at the above named event sponsored by New Life Assembly to be used by New Life Assembly in publications or promotional campaigns.
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Yes
No
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I agree to notify the Church in the event of any health changes, which would restrict my child’s/youth’s participation in any normal activities.
Required
*
By entering your name below, you are effectively providing your signature, indicating that you do hereby consent to the participation of your student in the above stated activity.
Required
Parent/Guardian signature
*
Your answer
A copy of your responses will be emailed to the address you provided.
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