Stars Sleepover Permission Form

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Friday and Saturday, June 5-6, 2023
6:00 p.m. - 10:00 a.m.

New Life Assembly of God
720 3rd Ave N
Ellendale, ND
701-349-5449

In addition to completing this form, the Yearly Medical Release form effective September 1, 2022 - August 31, 2023 must also be completed.

Student's Name *

Date of Birth *

Parent/Guardian's Name *

Best phone number to be reached at. *

Optional second phone number (work, cell, etc.)

Emergency Contact (other than above) Name and Relationship to child *

Emergency Contact Phone Number *

Optional Second Emergency Contact (other than above) Name and Relationship to child

Optional Second Emergency Contact Phone Number

MEDICAL INFORMATION: List any changes from the Yearly Medical Release form effective September 1, 2021 - August 31, 2022: *

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. *

Yes

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 *

Submit

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