Youth Permission Slip

Request Submission Date

Child First and Last Name

Child Age

Child Date of Birth

Parent(s)/ Legal Guardian First and Last Name

Phone Number

Additional Phone Number

Select an Address

I give permission for my child (named above) to attend activities, events, field trips, and service projects associated with Divine Glory Ministries, Inc. I further give permission for my child to be transported to and from events authorized by Divine Glory Ministries, Inc. in the year of 2024. I understand the organization will not be held liable for loss or damage of any personal or valuable property. I agree to ensure my child does not bring valuable or personal items to any activities or events. I understand that failure to adhere to this or any other rules established by this program will result in disciplinary action and possible suspension of my child(ren) from the program.

Have you read and understood the above statement?

Yes, I have read and understand the above statement

Liability Waiver:

I hereby release Divine Glory Ministries, Inc. its employees, agents and volunteers, from any and all liability, claims, demands, causes of action and possible causes of action whatsoever arising out of or related to any loss, damage or injury (including death) that may be sustained by my child while participating in or traveling to and from activities or events with Divine Glory Ministries, Inc.

Have you read and understood the above statement?

Yes, I have read and understand the above statement

Statement of Faith:

We believe that God wonderfully creates each person as male or female. These two distinct, complementary genders together reflect the image and nature of God. Rejection of ones biological gender is a rejection of the image of God within that person. We believe and will practice according to the Bible as we address children by their biological male or female assignment and name provided at birth.

Have you read and understood the above statement?

Yes, I have read and understand the above statement

Please Initial to acknowledge you have read and accept the practices of this organization and understand this will be followed as we engage yourself and your children.

Medical Release:

In the event I am unable to be reached and my child requires immediate medical attention, the hospital/ medical care provider of my choice is:

Provider Name

Provider Phone Number

Provider Address

I hereby authorize the volunteers at Divine Glory Ministries, Inc. hospitals, licensed medical or dental providers, and their agents and employees to have access to the information contained in this form and to provide simple first aid and all medical or dental care, routine tests, treatment, and necessary transportation advisable for the health and safety of my child.

Parent/Legal Guardian Print Name

Parent/ Legal Guardian Signature

Please upload a copy of the state issued ID's for the parents/legal guardians of the youth.

Upload Parent/Legal Guardian Photo ID

Health Care Information

Upload Parent/Legal Guardian Photo ID

Physician

Name

Number

Dentist

Name

Number

Medical Insurance Company

Policy/Group Number

Name of Policy Holder

Dental Insurance Company

Policy/Group Number

Name of Policy Holder

Please list any food allergies

Please list any medical allergies

Does your child wear glasses or contacts? If yes, please list

Date of last tetanus shot

Please list medication prescribed to your child, including (what it is taken for, when it is to be taken, dosage information, and prescription instructions

List reason medication is prescribed

Please write prescription instructions

Please list any additional information relevant to participating in Youth Group activities (dietary needs; surgeries or serious injuries; chronic or recurring illness; medical conditions such as epilepsy or diabetes; psychiatric counseling or indications, etc.):

Emergency Contact

List at least two (2) people that can be contacted in the event of an emergency and you are not reachable.

Emergency Contact #1 Name

Emergency Contact #1 Number

Emergency Contact #1 Relationship to Parent

Emergency Contact #2 Name

Emergency Contact #2 Number

Emergency Contact #2 Relationship to Parent

Do you grant permission for your child to participate in all water related activities?

Yes

Does your child have adequate swimming experience?

Yes

A Parent/Legal Guardian/Adult must be present during the time of pick up and drop off. Children are permitted to be dropped off at an alternative address to the child’s residence to approved adults listed on permission slip. List the adults authorized to receive your child. These adults cannot be known Sex Offenders.

First and Last Name

Age

Relashionship to Child

Is This Person a Know Sex Offender?

Yes

First and Last Name

Age

Relashionship to Child

Is This Person a Know Sex Offender?

Yes

Please upload a copy of the state issued ID's for both adults listed above.

Upload Emergency Contact #1 Photo ID

Upload Emergency Contact #2 Photo ID

Parent/Legal Guardian Print Name

Parent/ Legal Guardian Signature

Has your child been potty trained

Yes

Due to a staffing shortage, parents must accompany children that are not potty trained to all youth activities hosted by Divine Glory Ministries, Inc.

Please initial next to the condition that applies to your child.

My child is of age and knows how to independently use the restroom.

My child needs assistance with using the restroom and I thereby give permission for my child to be assisted in according to restroom policies and procedures of Divine Glory Ministries, Inc.

Media Release

Safety Recording Notice:

Divine Glory Ministries, Inc. van and premises is under surveillance to ensure the safety of members, youth, and property. Your child(ren) will be recorded while on the van and in the common areas of the premises. No child(ren) that attend services with Divine Glory Ministries, Inc. will be able to opt out of this as this is required for safety purposes.

Have you read and understood the above statement?

Yes, I have read and understand the above statement

Request for Consent:

Divine Glory Ministries, Inc. (DGM) would like your consent to take and share identifiable photos and videos of your child(ren) for the purpose of publication, promotion, illustration, or advertising the ministry work of DGM in any manner or medium. I understand I will not be compensated for any photos or media recordings used for the advancement of (DGM) mission and vision.

Have you read and understood the above statement?

I Consent

I DO NOT Consent

Physical Safety:

Considering the times that we are all living in, we are now using a metal detector scan on all individuals who enter the van for everyone's comfort and safety. This may require bag searches of youth personal property to ensure that there are no weapons on their person or possessions.

Have you read and understood the above statement?

Yes, I have read and understand the above statement

Hygiene Education:

As a ministry, we believe in preparing people holistically to live successfully. As a result, we are asking your permission to teach your prepubescent child about hygiene and managing their menstrual cycle by providing them with supplies should they need it.

Have you read and understood the above statement?

I Consent

I DO NOT Consent

Thank you for your submission