Student Name *

First Name

Last Name

Student Phone #

Add only if we are allowed to send text for information purposes to the student #

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Parent/ Caregiver Name #1 *

First Name

Last Name

Parent/Caregiver Cell Phone #1 *

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Parent/ Caregiver Name #2

First Name

Last Name

Parent/Caregiver Cell Phone #2

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Check all that apply

I give permission for youth named above to attend Fusion's weekly programming, retreats, events & outings..

I authorize Fusion Youth Ministry and their staff to use photographs, video images, or other likenesses of myself and/or my child for the purposes of our website, and social media sites and/or other ministry material.

I also grant permission, in case of emergency, for medical attention to be sought by leaders of my student’s group and/or the persons in charge, if I am unable to be contacted. I understand that I will be notified immediately of any such happenings.

I expressly assume any and all risks of injury arising from or relating to the activities I have given my child permission to participate with Fusion Youth Ministry and waive and release any and all suits or demands of any kind or nature whatsoever against Fusion Youth Ministry, staff, volunteers, or representatives arising from or relating in any way to the participant’s voluntary participation in said activities.

I understand that my youth will behave in a manner that is appropriate. If my youth’s behavior is deemed inappropriate or violent, that I will be asked to come and take my youth home – or they will be sent home at my expense.