Youth Permission Slip

  • This Permission Slip is applicable to all Christ Church Cranbrook youth activities from September 1, 2016 - August 31, 2017.

  • Parent/Guardian Information

    If parents live at different addresses, list both, and indicate which is the primary residence
    **If there are special custodial arrangements, please notify CCC Youth Ministry **
  • Person to notify in case Parent/Guardian CANNOT BE REACHED

  • Health and Medical Information

  • **If you have special dietary needs, please do let us know. We will try to accommodate all requests
  • The following is a list of medications that my child will need to take while attending Christ Church Cranbrook activities. (Please attach a list if additional room is needed.) All prescription medication must be properly labeled in its original pharmacy container. Over the counter medication must also have the youth’s name written clearly on the container.
  • I give permission for my child to receive the following over-the-counter medications from an adult sponsor:

  • Covenant

    • To respect the dignity of every human being
    • To support the group by participating fully and listening to others with respect and an open heart.
    • To be drug, alcohol and tobacco free
    • To turn in any over the counter or prescription meds to adult leaders to be administered as directed by a physician/ parent
    • To not engage in sexual behavior
    • To participate in a way that won’t detract from others’ experiences
    • To remain in supervised areas at all times
    • To treat the host’s property with respect
    • To not be in an opposite gender’s sleeping area

    I understand, should I not abide by this Covenant, that my participation in Christ Church Cranbrook youth activities may be cut short, my parents contacted, and I may be sent home from an event at the expense of my parents.

  • Parent/Guardian Authorization & Signatures

  • PARENTAL CONSENT:

    I give full permission for my child to attend and participate in any youth activity sponsored by Christ Church Cranbrook between September 1, 2016 and August 31, 2017.

    DURABLE POWER OF ATTORNEY FOR EMERGENCY MEDICAL/SURGICAL CARE:

    I represent and warrant that to the best of my knowledge my child has no illness, congenital defect, or other health condition that makes my child’s participation in Christ Church Cranbrook youth activities unsafe for my child or other participants even with reasonable accommodation of any disability.

    I appoint Christ Church Cranbrook (470 Church Road, Bloomfield Hills, MI 48304) as my agent pursuant to MCLA 700.5103 for the limited purpose of consenting to any emergency medical or surgical care for my child that may be recommended by a physician regarding any injury or illness that may arise while my child is participating in a Christ Church Cranbrook youth activity. Christ Church Cranbrook shall use its best efforts to contact me in advance of exercising this delegated power so that I may direct my child’s care. If I am unavailable after reasonable attempts to contact me, or if my child’s condition makes any delay medically unadvisable, then Christ Church Cranbrook may exercise the delegated power without communicating with me first.

    I agree to pay all health care providers for any services rendered to my child pursuant to this delegated power, whether through health insurance or private payment.

    TRANSPORTATION RELEASE:

    I give full permission for my child/children to be transported to Christ Church Cranbrook youth activities between September 1, 2016 and August 31, 2017, which includes permitting my child to attend and participate in activities off site of the Christ Church Cranbrook campus.

    WAIVER OF LIABILITY:

    I release Christ Church Cranbrook, its agents, employees, officers, vestry members and volunteers, from any liability of any kind or nature that may arise in any way from my child’s participation in Christ Church Cranbrook youth activities.

    MEDIA RELEASE:

    I give permission for photographs or video of my child or myself to be taken during my child’s or my participation in Christ Church Cranbrook youth activities, to be used by Christ Church Cranbrook for promotional purposes.

  • Send payment to:
    Christ Church Cranbrook, Youth Ministry, 470 Church Road, Bloomfield Hills, MI 48304