MT HOPE BAPTIST CHURCH
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Mt Hope Baptist Church Van Rider Permission Form
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Parent/Guardian Name #1
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Last
Parent/Guardian Name #2
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Last
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Address
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Email
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Phone Number
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Phone Number
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Person(s) generally responsible for Check-In/Pick-UP
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Additional Emergency Contact
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Relationship
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Emergency Phone
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Student #1
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Date of Birth
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Age
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School
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Grade
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Child's Relationship To You
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Son
Daughter
Other
If other, please indicate relationship:
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Student # 2
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Last
Date of Birth
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Age
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School
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Grade
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Child's Relationship To You
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Please Select
Son
Daughter
Other
If other, please indicate relationship
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Student #3
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First
Last
Date of Birth
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Age
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School
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Grade
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Child's Relationship To You
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Please Select
Son
Daughter
Other
If other, please indicate relationship
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Do any of the above have food or medication allergies?
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Yes
No
Do any of the above have any serious medical or behavioral issues we need to be aware of?
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Yes
No
If you answered yes, please list here.
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I hereby consent to my child(ren) listed below to ride the church van for programs and activities sponsored by Mt Hope Baptist Church (MHBC) Student Ministries. These activities include but are not limited to Sunday School, Midweek Services, and VBS. I certify that my child is able to participate in these activities. I also recognize that van seating is limited to those with a transportation hardship and acknowledge my child(ren) would have no or very limited access to MHBC activities without a pickup by the church van.
Agree
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Yes
No
Van Rider Rules
Student will remain at church after arriving and will not leave the church property for any reason.
If a student rides the van, they will ride it home the same day. Written parental consent is necessary if the rider will go home a different way.
Student will not possess or use any drugs, alcohol, or tobacco.
Student will not possess any knives, fireworks, weapons and/or guns of any kind.
Student will not swear or participate in any “off color” conversations.
Student will refrain from bullying, name calling, or fighting with other participants.
Student will refrain from all romantic displays of affection.
Student will respect the authority of the van driver and adult leaders and will follow all instructions.
Student will not ask, nor expect, the driver to let them off the van at any other place except their regular stop.
Student will treat the van with care and will refrain from abusing it in any way.
Student will not ride the van if under doctor’s orders not to attend school or if student has been displaying symptoms including flu like symptoms, fever, nausea, or vomiting.
Students will be checked by touch free thermometer. Any child with a temperate over 99.9 will not be permitted to ride the van that day.
Parent/Guardian: I understand that while my child participates in any church-sponsored activity, he or she is responsible to abide by the rules set forth by the church, its leaders and supervisory personnel. Any serious infraction of these rules by my child(ren) can result in loss of riding privileges. I agree to assume the responsibility of returning him/her home.
Agree
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Yes
No
By submitting this information, I give my permission for my child(ren) listed above to ride the Mt Hope Baptist Church van to attend church functions. I understand my child(ren) will be under adult supervision. I further understand that in signing this permission slip, I release and hold harmless Mt Hope Baptist Church. By submitting this permission form, I release and hold harmless its trustees, officers, employees, and volunteers for any liability. I authorize the staff or designated medical professionals and/or volunteers to administer emergency assistance if I cannot be reached.
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