Youth Trip Permission Form — First Pentecostal Church Of North Little Rock

youth trip

permission & medical form

Please complete the following information so that you or your student may participate in all the exciting events we have planned for the year. This form applies to all trips and activities for the year 2025.

NOTE: The Signup for the Union City Youth Trip has closed. However, if you have not already done so, students will still need the permission form completed in order to attend.

CHURCH REPRESENTATION GUIDELINES
Realizing that it is a privilege to go on special youth trips, it is important for every young person to remember that they are not only ambassadors and representatives for our church and Pastor Holmes, but also for Jesus Christ. With this in mind, we encourage every young person to conduct yourself in such a way that you would be above reproach, and an example to others. The list below serves as a guideline that every young person will be expected to adhere to.

ALL: No worldly music, magazines, books, or literature of any kind. Sleeves worn below the elbow.
YOUNG MEN: Clean shaven with a good haircut, above the ears and collar, and off the forehead. No ragged or torn clothing worn to service.
YOUNG LADIES: Dresses and skirts worn well below the knee. Dresses and skirts worn without splits. Uncut, uncolored hair. Hair that has been cut must be worn up and pinned back. No make-up of any kind. Shirts and blouses within three finger’s- width of the collarbone.

We would also like to stress the absolute importance of every young person staying in his or her room once the group is at the hotel for the night. Sadly, there are crimes committed every day with young people as the victims, and it would be a tragedy for such an occurrence to take place on a trip such as this. We take this rule very seriously. Any offenders will be banned from any youth trips for the rest of the year.

General Information

Please complete a separate form for each Student/Participant.

Student/Participant First Name

Student/Participant Last Name

Grade or Group

Parent or Guardian First & Last Name

Additional Parent or Guardian First & Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Information

Student Cell

Parent or Guardian Cell

Parent or Guardian Work Phone

Additional Parent or Guardian

Emergency Contact

In an emergency when parent/guardian cannot be reached, please contact the following:

Name

Phone

Relationship to Student/Participant

Medical

Allergies & Health Concerns

Please identify any allergies (including foods), health problems, medications, or other health concerns.

Family Physician & Phone Number

Medical Insurance Company & Group Number

Policy Holder's Name & Policy Number

Additional Information That May Be Helpful

Legal

DISCLAIMER First Pentecostal Church and its leaders, directors, officers, employees, contractors, agents, volunteers, members and representatives (collectively referred to as “First Pentecostal Church and/or FPC”), are not responsible for any injury, loss or damage of any kind whatsoever sustained by any person or their property while participating in events, activities or travel with First Pentecostal Church and all related activities associated with the First Pentecostal Church, including injury, loss or damage. ASSUMPTION OF RISKS IN CONSIDERATION OF First Pentecostal Church allowing me or my child to participate in events, activities, or travel with FPC and all related activities associated with the FPC, including participation in the Youth Group for the current year inclusive, and all activities related to the Youth Group (collectively referred to as the “Activities”), I acknowledge that I am aware of the possible Risks, Dangers and Hazards associated with participation in the Activities including the possible risk of severe or fatal injury to myself or others. RELEASE OF LIABILITY and AGREEMENT IN CONSIDERATION OF First Pentecostal Church allowing me or my child to participate in the Activities, I agree on behalf of myself and/or my child: 1. TO ASSUME and ACCEPT ALL RISKS arising out of, associated with or related to my or my child’s participation in the Activities. 2. TO WAIVE and RELEASE First Pentecostal Church from any and all liability for any loss, damage, injury or expense that I or my child may suffer, or that my next of kin may suffer as a result of my or my child’s participation in the activities due to any cause whatsoever. 3. TO INDEMNIFY and HOLD HARMLESS First Pentecostal Church from any and all liability for any damage to the personal property of, or personal injury to, any third party resulting from my or my child’s participation in the activities. 4. TO INDEMNIFY and HOLD HARMLESS First Pentecostal Church from any and all claims, demands, actions and costs for any loss, injury, damage or expense whatsoever that might arise out of my or my child’s participation in the Activities. YOUTH PARTICIPATION CONSENT Acknowledgment of Participant: I, the undersigned Participant, understand that I will uphold the GUIDELINES set forth by FPC, I am responsible to act in a safe and responsible fashion, to follow the instructions and directions of the persons in charge of the Youth Group, and to obey requests to comply with safety regulations as directed by the persons in charge of the Youth Group, including designated leaders and drivers of private or public transportation. I will be solely responsible for myself, will wear a seat-belt when available and will not disturb or distract the driver when using private or public transportation to travel to and from Youth Group activities. At all Youth Group sports events or other activities, I acknowledge that it is my responsibility to obtain and wear appropriate safety equipment. I will not endanger the safety of others or myself at any activities, outings or sports events of the Youth Group or when using private or public transportation for travel to and from such activities. I also understand that I may be photographed or appear in video for such purposes as FPC deems necessary. Acknowledgment of Parent or Guardian of Participant: We, the undersigned Parents or Guardians of the Participant, hereby authorize and consent to the Participant’s involvement in the Youth Group, including any use of private or public transportation deemed necessary by the persons in charge of the Youth Group for Participant travel to and from Youth Group activities, or to the NEAREST SUITABLE MEDICAL or HOSPITAL FACILITY in the event that emergency or other medical treatment not available at the site of a Youth Group activity is deemed advisable. We hereby consent to and authorize such emergency or other medical treatment of the Participant as may be deemed advisable in the event of accident, injury, or illness during the activities of the Youth Group. ACKNOWLEDGEMENT and SIGNATURE I UNDERSTAND THAT THIS IS A LEGAL AGREEMENT that is binding upon myself and my heirs, executors, administrators, successors and assigns. I HAVE READ AND UNDERSTAND THE TERMS OF THIS AGREEMENT and I ACKNOWLEDGE THAT by signing this agreement voluntarily, I am agreeing to abide by its terms and I am waiving certain legal rights that my child or I may have. This Consent, Authorization and Acknowledgment shall be effective from and including January 1 - December 31, 2025.

Electronic Signatures

Electronic Signature of Parent or Guardian

If Student/Participant is under 18 years of age

Electronic Signature of Participant/Student

Date Signed

YYYY

youth trip

permission & medical form

FIRST PENTECOSTAL CHURCH OF NORTH LITTLE ROCK

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