CrossTown Student Information & Permission Form Student Name * First Name Last Name Preferred Name * Preferred Pronouns * Date of Birth * Grade (2023-2024 School Year) * Parent/Guardian Name(s) * Full Street Address * Home Phone * (###) ### #### Parent/Guardian Phone(s) * Allow Texting * Please check one of the following: Yes No Parent/Guardian Email(s) * Student Phone (if applicable): (###) ### #### Allow Texting * Please check one of the following: Yes No N/A (no student phone) Student Email (if applicable) School * Home Church * Emergency Contact (other than Parent/Guardian) (name & phone) * INSURANCE INFORMATION: Please email a copy of your student's insurance information to Abby Glass at goodphilipyouthfamily@gmail.com or provide details in the field below. * Is your household vaccinated against COVID-19 * Please check one of the following: Yes No Prefer to not answer Please list current medications * Known Allergies * Dietary/Physical/Other Restrictions * My child may participate in Ecumenical Youth Group activities with First United Methodist Church, St. Philip's Episcopal Church, Lutheran Church of the Good Shepherd, and Bethal A Baptist Church, including weekly activities, special trips and excursions under the supervision of approved Church Volunteers. This includes permission to ride on a Church Bus belonging to one of the four churches listed above, with an approved driver. * I give permission for my child to be photographed, and for CrossTown to use individual and group photos in its publications, both in print and online. * I hereby authorize any adult volunteer to give consent for medical treatment of my child in the event of illness or injury. I further release First United Methodist Church, St. Philip's Episcopal Church, Lutheran Church of the Good Shepherd and Bethel A Baptist Church, their employees and their volunteers from any liability int he event of any accident enroute, during, or returning from any church event and/or trip. In case of emergency, I understand that every effort will be made to contact me as a parent or guardian. in the event that I cannot be reached, I hereby give permission to the physician or medical professionals selected by the church representatives to hospitalize and secure proper treatment for my child. The authorization is effective for the individual named above for a period of one year from the date submitted. * Signature of Parent or Guardian: I understand that my typed name below is recognized as the electronic equivalent of my handwritten signature on a hard copy form. * Submittal Date * Thank you for submitting the CrossTown Student Information & Submittal Form. Your information has been sent directly to Abby Glass.
