Sex ________ Date of Birth _________________

NAME OF PARENT/GUARDIAN_______________________________________________________

Home Address_____________________________________________________

City ______________________________ State ____________ Zip ______________

Home Phone (_____)_________________Work (_____)_________________

In case of an Emergency please contact: ____________________________________________

Relationship: _____________________________________ Phone No: (_____)_________________

I, [Parent/Guardian named above] grant permission for my child [Participant named above] to participate in the event named below. I understand that this event will take place under the guidance and direction of the KIX sponsors and other volunteers from Trinity United Methodist Church. I also understand that, if transportation is provided by Trinity, all drivers will be over the age of 22. My understanding of the event is:

Event: ______________________________________________________________________________

Place/Destination: ____________________________________________________________________

Date(s) and Tine(s): ___________________________________________________________________

As parent/legal guardian, I remain legally responsible for any personal action taken by my child. I agree to hold harmless this church [named above], and all sponsors or representatives associated with this event, arising from or in connection with my child attending this event, or including but not limited to accidents, emergencies, exposure to reckless conduct of persons.
 

PARENT/GUARDIAN SIGNATURE:_________________________________________ Date ___________