Student Ministry Permission Form - South River Baptist Church

Parent/Legal Guardian's Name*
I give permission for my child to take part in this activity
First Last
Child/Youth's Image Consent*
I hereby grant/do not grant permission for my child's/children's) image to be included in pictures, videos, promotional materials, and publications connected with South River Baptist Church.
- I grant permission
- I do not grant permission
Child/Youth's Name*
First Last
Activity Name*

Sponsored by South River Baptist Church on this date.
Activity Date*
MM slash DD slash YYYY
Emergency Contact Name*
First Last
Emergency Contact Phone*
Parent/Legal Guardian Signature (typed name)*

I am fully aware that there will be ample supervision for this event. I have completed and witnessed the notorization of a Medical/Liability Release Form for my child. By signing (typing in your name) this permission slip, I am confirming that the information on his/her Medical/Liability Release Form is current and up to date. I understand in the unlikely event of an accident or emergency that my child will receive adequate care based upon the information given.
Email*
Enter Email Confirm Email
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.

2659 S. Chipley Ford Rd.

Statesville, NC 28625

704-876-1520

southriverbaptist.com