Church Van | The Worship Room

Name (Required)

Email Address (Required)

Child(ren)'s name if under age of 18?

If you have a child needing to ride the van under the age of 18 please list their name. If multiple children will be riding please separate with a comma.

Your Phone Number (Required)

Your Address (Required)

Allergies or Medical Info (Required)

Please list any allergies, medical information, or medication we might need to be aware of.

Emergency Contact (Required)

In the event of an emergency, who do we contact? Phone number?

I give my child(ren) permission to ride The Worship Room church van to attend services at The Worship Room. I understand my children will be under adult supervision at all times. (Required)

By Typing my name below I agree to the following... (Required)

I understand that by signing this form, I release and hold harmless The Worship Room Inc. By signing this permission slip, I release and hold harmless its trustees, officers, employees and any volunteers from any liability, past or future, fully and completely. I authorize the staff or designated medical professionals and/or volunteers to administer emergency medical assistance if I or emergency contact cannot be reached.

The Worship Room

106 S Public Square
Greensburg KY 42743

(270) 405-2005

TheWorshipRoom.KY@gmail.com

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