“One Day” Permission Slip This Permission Slip is only valid for the “One Day” Event. An additional Permission Slip will require to attend XZone/SunHouse in the future. “One Day” Permission Slip I give permission for my student to attend the: "One Day" Event * Yes No Student's Name * First Name Last Name Birthday * MM DD YYYY Gender Female Male Grade * Please select your student's current school grade 5th 6th 7th 8th 9th 10th 11th 12th Code of Conduct - Student Agreement * At LJPres programs, events and trips we expect our staff, volunteer leaders, and students to uphold our values of safety and respect. If our staff feels a student has said or done something that violates these values, we will remove the student from the activity. An immediate parent/guardian phone-call will occur, and we may ask the parent/guardian to come pick up their child before the activity’s scheduled conclusion. Please talk with your child about our expectations for behavior and conduct! All students should keep their hands and feet to themselves at all times. We have a zero-tolerance policy for inappropriate contact. One seat per person. No lap-sitting or sharing seats. No hate-speech or slurs of any kind. We have a zero-tolerance for any form of bullying. Do not spend unnecessary time in our restrooms. Use restrooms when needed, then promptly re-join the program. Phones are collected and stored safely in the phone-zone. Practice mutual-respect. Our staff and volunteers care for you; please respect their instruction and leadership. Parent(s) Section Parent #1 Name * First Name Last Name Parent #1 - Email * Parent #1 Phone Number * (###) ### #### Parent #2 First Name Last Name Parent #2 Email Parent #2 Phone (###) ### #### Family Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name Of Emergency Contact First Name Last Name Emergency Contact relation to Student Emergency Contact Phone Number Line General Release - Participation I, as primary guardian of the aforementioned student give permission for my student to participate in the "One Day" Event - November 2, 2024 First Name Last Name General Release - Participation I, as primary guardian of the aforementioned student give permission for my student to participate in the "One Day' Event - November 2, 2024. Release * La Jolla Presbyterian Church (LJPC) from all responsibility related to medical issues, illnesses, or injuries that may occur to my child during any "One Day" activities at the event. The Participant/parents/legal guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or event and releases and promises to indemnify, defend, and hold harmless LJPC, the LJPC staff, volunteers, or other attendees for any illness or injury arising directly or indirectly out of the activities or events. I acknowledge that participation in the activities or events involves risk to the Participant. No matter the injury, I acknowledge and accept the risks of injury associated with participation in the event. I further accept full responsibility for any medical expenses that may be incurred in the event my child needs emergency medical treatment and I promise to indemnify, defend and hold harmless LJPC, LJPC staff and volunteers, or other attendees for any medical expenses incurred by my child. Yes Departing from Program/Events * APPLIED TO ALL STUDENTS AND CHILDREN I agree to pick up or arrange for my student to be picked up from program/event within 10 minutes of stated end time. Yes Films I agree to allow my child to watch any films rated G, PG, or PG-13 which may be shown (at the Youth Director’s discretion) as devotionals, bible study segments, or for entertainment purposes. I understand that whenever possible, film titles will be provided ahead of time. I understand that the youth leaders will never show an R rated movie without my permission and a separate permission slip will be provided if such a case were to occur. Yes No Media Consent * I hereby give my full consent to La Jolla Presbyterian Church (LJPC) and its ministries to record (video, photograph, audio, recording or other) my and my child's participation in any programs or events associated with LJPC "One Day" Event. Further, I hereby transfer and assign to LJPC the exclusive rights to use and to authorize others to use said images, video, photography, audio recordings or other, for promotional and educational use or resource sale in the future. I understand that my and my child’s image, voice or video recording may be used, but my name or personal information will never be shared publicly without additional, separate consent. Yes No Digital Signature - I have agreed to submit this permission slip by electronic means. By signing this permission slip electronically, I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. * Line This form is not completed until you send a picture of your driver’s license to lizzetf@ljpres.org to identify your digital signature. Thank you! Show your brand. Make it shine.
