Parent Permission Release Form - ALL Events Wakarusa Missionary Church Minor
Dear Parent of Minor,

On this form you will find different sections related to parental permissions needed prior to students' engagement in any events or activities with Wakarusa Missionary Church. Our best interest is the safety of your minor and family as a whole. The following items are included: 

● Insurance Portion of Permission Form
● Photo Release Form
● Student Ministry Activity Form
● Any activities WakyMC is transporting your child(ren) will require this form to be
filled out

This form only needs to be filled out ONCE and is good through 7/31/2024. Thank you
for your time and kind agreement to comply. If you have any questions, please direct
them to Pastor Dustin Eby: deby@wakymc.org or Tyler Gerig: tgerig@wakymc.org
Sign in to Google to save your progress. Learn more
Wakarusa Missionary Church Parental Permission
Student(s) name(s) *
Grade(s) In School *
Student(s) DOB *
Allergies/Medical Concerns: Please list any medical concerns such as allergies (peanut,
gluten, etc.), medications (Tylenol, Advil, etc), etc, which pertain to your student:
I give my student(s) permission to
participate in all activities at all locations between the following dates: 1/1/2023 to
7/31/2024.
 *
Required
Parent/Guardian Name(s)  *
Address *
Phone *
Parent/Guardian Email *
Medical Release
I agree and consent to having a staff member of the Wakarusa Missionary Church give
permission for my student to receive medical attention in the event of an accident or
illness while attending any event. This includes travel to and from the event/activity as
well as the event/activity itself. I accept responsibility for any and all financial obligations
incurred for such treatment.
Do you have medical insurance? *
Policy Holder *
Policy # *
Emergency Phone Number(s) *
WakyMC Minor Photo Release Form 
I hereby, authorize Wakarusa Missionary Church (WakyMC), to publish the photographs
taken of me and/or the undersigned minor children and our names, for use in the
WakyMC printed publications, website or social media. (Ex: informative Facebook page
for each department.)

I give permission to WakyMC to copyright, use and publish the photographs of my child
with or without names for any lawful purpose, including illustrations, advertising and web
content.

I release all claims against WakyMC with respect to ownership and publication including
any claims of compensation. I confirm that I am the parent or legal guardian of the
minor child(ren) and have the authority to authorize them to use their photographs and
names.
Do you agree to the statements above? *
SM Activity Permission Form
Student Ministries is very active on & off church property: Student Conferences,
Spiritual Growth Retreats, house parties, etc. We are very excited about having such a
large variety of events/activities for your student(s) to get involved in, however, the large
list of activities increases the potential accidental injury to occur. Every activity we
participate in will be logged on the WakyMC calendar, meaning, WakyMC insurance
policy/coverage will be activated for your student in case of emergency and injury. This
Permission Form is meant for a 1 time signature of protection for you student(s) and
WakyMC. Any questions about the purpose of this form and logistics, please contact
Pastor Dustin Eby: deby@wakymc.org or Tyler Gerig: tgerig@wakymc.org
In consideration for the below-named student’s participation Student Ministry random
event/activity, I, for myself and on behalf of the below-named student agree to release
the Wakarusa Missionary Church, its officers, directors, and agents and anyone

connected or associated with the church from any liability for injuries to the below-
named minor arising out of his/her participation in the SM random event/activity,

including during their transportation to and from said event/activity.
Do you agree to the statements above?  *
Parents and Students, please read and discuss the following:
On all of our events, we have certain expectations regarding behavior which will ensure that we all have a
great experience. If, during this event, you are unwilling to maintain these expectations,
please understand that your parents will be notified. Further, should it be necessary for
the participant to return home due to disciplinary action or otherwise, parents will
assume all transportation costs. Please sign below indicating that you understand this
and agree to cooperate.
By typing your name below, you agree to the medical release, photo release, activity permission, & the behavioral expectations. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Wakarusa Missionary Church. Report Abuse
Google Forms