Permission Slip - For students in the Nursery - 5th Grade

I give permission for my student to attend all the calendared promoted events: Sunday School, Tuesday's Parenting Class, One Day Event, H.U.G.S, X-Zone Program on Wednesdays, X-Zone Movie Nights, X-Zone Winter Camp, X-Zone Summer Camp, and La Jolla Presbyterian Church Vacation Bible School (VBS). *

Yes

No

If you checked no: My student only has permission to attend the following event(s). Please select all that apply.

X-Zone Program on Wednesdays

X-Zone Movie Nights

X-Zone Winter Camp

X-Zone Summer Camp

VBS - June 24th - 28th

Sunday School

Tuesday's Parenting Class

One Day Event

H.U.G.S.

Student's Name *

First Name

Last Name

Birthday *

MM

DD

YYYY

Gender

Female

Male

Parent #1 Name *

First Name

Last Name

Parent #1 Phone Number *

(###)

###

####

Parent #2

First Name

Last Name

Parent #2 Phone

(###)

###

####

Family Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name Of Emergency Contact

First Name

Last Name

General Release - Participation

I, as primary guardian of the aforementioned student give permission for my student to participate in X-Zone activities and events both on and off of the La Jolla Presbyterian Church (LJPC) campus for the period of August 1st 2023 - August 1st 2024

First Name

Last Name

Release

La Jolla Presbyterian Church (LJPC) from all responsibility related to medical issues, illnesses, or injuries that may occur to my child during any X-Zone activities or at any X-Zone events. 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

No

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

No

Calendar Events

I give permission for my student to attend calendared promoted events at X-Zone, VBS and Sunday School.

Yes

No

Leaving the church campus

I give permission for my child to leave the church when supervised by the youth leadership for appropriate activities related to X-Zone (i.e. Christmas Caroling)

Yes

No

Transportation

I give permission for my child to be transported by bus, van, or car to and from church events that happen offsite.

Yes

No

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 X-Zone. 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

X-Zone Refund Policy

All X-Zone event payments can be refunded in full (30) days prior to the event. After the (30) day mark, half of payment will refunded. (1) week before the X-Zone event no refunds will be given. This policy is in place because of the logistics involved in reservations regarding student attendance; including camps, lodging, food budget, facility rentals, and extra cost given by vendors for X-Zone events. By clicking yes, I agree to the X-Zone Refund Policy

Yes

No

I would like to be added to the X-Zone email list so that I can stay informed about upcoming events and announcements.

Yes

No