Permission Form

9700 S US HWY 377 – Tishomingo, OK 73450 – (580) 371-9296

A C T I V I T Y     R E L E A S E     F O R M

Student Information

Name _________________________________________________________Gender_________

Grade _________________ Date of Birth ___________________ Cell _____________________

Address, City, State, Zip __________________________________________________________

Parent / Guardian Information

Name _________________________________________Email___________________________

Home Phone _____________________________ Other Phone __________________________

Medications / Allergies or Special Notes to be considered


P E R M I S S I O N      F O R M

STUDENT – I promise to abide by all rules and plans set forth by the leaders of Calvary Baptist Church Student Ministry during the course of this or any event.

STUDENT SIGNITURE ____________________________________________________________

PARENT – I / We are the legal guardians of the student named above and hereby give my/our permission for the named student to participate in student events with the leaders of CBCTISH student ministry for this event. I understand that in the event of an emergency that the leaders of CBC TISH Student Ministry will do everything in their power to contact me personally, but that in the event they are unable to do so, I/we give my/our permission for the leaders to seek necessary medical attention for the student above. I/we assume all risk of personal injury, sickness, damage and expense as a result of participation by the above named child. I/we also release, forever discharge, and agree to hold harmless Calvary Baptist Church and the staff and director thereof from any and all liability claims for personal injury or sickness which may be incurred by the undersigned.

PARENT SIGNITURE _____________________________________________________________

NAME, LOCATION AND DATE OF EVENT _____________________________________________