Permission Form

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
School Name
Age
Grade
Parent/Guardian Information
Name
First Last
Phone
Email
Relationship:
Parent/ Guardian Information
Name Phone Relationship
Allergies/ Special Needs:
Parental Responsibility Statement

I give permission for my child to attend St. Luke A.M.E. Church youth activities. My child has been told the value of this program, the need to cooperate with adults and volunteers, and proper conduct.

I will be responsible for seeing that my child arrives prepared to participate and on time. I will see to it that my child is picked up on time, as well. I will notify the program immediately if the person(s) scheduled to deliver and/or pickup my child changes at 219.397.1626.

In addition, I volunteer to support this program by assisting with scheduled activities when possible.
Parent/Guardian Signature
Expectations for participants
- Follow rules and safety guidelines.
- Respect adults, volunteers, and other participants.
- Be an active participant in the program and have fun.
St. Luke A.M.E. Church

PERMISSION TO USE IMAGES

This form seeks your permission to use your child’s image as part of St. Luke AME Church youth ministry and activities. The images may be used on St. Luke’s print or digital media, news releases, grant reports and proposals, and educational videos related to the ministry.
Name
First Last
Phone
Email
Signature:
Date
MM slash DD slash YYYY

Youth Application

Name	Phone	Relationship