IY Permission Form

IY Permisson Form

We look forward to our time together with your youth!

If you have any questions, I welcome you to reach out to me at tlong@ibcrichmond.org; or (804) 426-4069.

Thomas Long
Student Ministries Pastor

Permission for Which Event?(Required)

Student Info

Student Name(s) + BIRTHDATES

PLEASE CONFIRM that all of your children are listed.

Parent/Guardian Info

Parent/Guardian Names(Required)

Email(Required)

Home Phone(Required)

Cell Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Emergency Contact Info: 1) Name, 2) Phone Number, 3) Relationship to Student(Required)

Medical Information

Please list 1) Allergies; and/or 2) Medications

Doctor’s Name and Phone Number(Required)

Medical Insurance Company and Group Number:(Required)

Authorizations

People authorized to pick up my student after the event:(Required)

DRIVING PERMISSION / I give my permission for the student above to ride with:

Any adult Immanuel Youth volunteer (background checked)

A parent chaperone (Please list their name) below.

If you choose a specific parent chaperone to drive, please list their name:

Date

IN PLACE OF A SIGNATURE, ONCE YOU FILL THIS OUT, PLEASE TEXT OR EMAIL PASTOR THOMAS TO CONFIRM IDENTITY. THANK YOU!

PASTOR THOMAS LONG | tlong@ibcrichmond.org | (804) 426-4069.

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