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First and last name:
Age: _____________________ Date of Birth: ______________________
Address: ______________________________________________________
City: __________________________ State: _______ Zip: _______________
First and last name:
Check one: _______Mother _______Father _______Legal guardian
Address: ______________________________________________________
City: __________________________ State: _______ Zip: _______________
Phone number: _________________________________
Email (optional): ________________________________________________
Emergency contact first and last name:
Relationship to Participant: __________________________________
Phone Number: ____________________________ ________________


Starting February 2016, there will be a monthly participation fee for each child who is regularly involved
in program. This includes those who receive weekly or monthly rides to and from group activities as well
as those who do not receive rides. If participants have been to more than 3 of any group real
activities/events and are consistently attending said events, then fees are expected to be paid for in full to
Group Real. this monthly fee will help to pay for weekly traveling expenses and weekly snacks for
program. the monthly fee will be $3 per child ($3/month for each child). this fee will be due on the last
Friday of each month. Parents/legal guardians will be sent at least one reminder (by text of paper) of dues
per month, at least a week before dues are due.
, understand that I am required to pay $3 each
month for each child of mine that attends the Group Real program. I agree to pay the fee of $3 per month
before or on the said due dates.
When new shirts are purchased parents will be required to pay for the shirt in full. Shirts will not be
purchased for your child if monies aren’t collected by due date. Parents will be notified of new shirts at
least one-month prier to the ordering of shirts.
T-shirt size (Circle One): S M L XL 2XL
At each session there is always snack provided for everyone. This snack always consists of some type of
food and juice or water. If your child has any type of food allergy, please be sure to specify in the section
Allergies: _____________________________________________________
I understand that my child’s participation in Group Real is a privilege, and not
a right. I acknowledge that I have spoken with my child about my child’s need
to comply with the specific rules and requirements established for this
activity; all policies, procedures and rules I understand that all rules and
policies apply to my child and the other students during all Group Real
Circle One: YES / NO


My child, ________________________________, has my permission to participate in Group Real to the
full extent of the program. I understand that these activities may involve travel to and
from group activity site. I also understand that one of two activities per year may
involve staying overnight (i.e. Slumber parties, group/ministry lock-ins).
I understand that Group Real has the right to dismiss my child and contact me to pick my child up from
the program in the event that a problem arises, which cannot be resolved. I do release Group Real and the
program sponsors/leaders from any and all liability for claims of illness, injury or accident excluding any
negligence of Group Real or its agents during participation in this program. This includes injury relating
to accidents that may accrue while traveling to and from activates beyond the claim of the driver’s
personal vehicle insurance. I understand that I am responsible for the expenses of my child’s medical
care. In case of emergency at a time when I cannot be reached, I authorize Group Real and program
leaders to reach the persons whose names have been listed on my child’s registration sheet.
I understand that these activities may involve travel to and from group activity site.
I also understand that one of two activities per year may involve staying overnight
(i.e. Slumber parties, group/ministry lock-ins).
I give Group Real permission to use photographic/video images of my child that show my child
participating in any activities or events in relation to Group Real for display on their website,
presentations and/ or publications. This authorization may not be revoked except by my providing written
notice of such revocation to a Group Real leader. If I revoke this authorization, I agree that Group Real
will have a reasonable amount of time (up to 3 weeks) to remove photographic/video images from its
website, presentations and/or publications any and all video and/ or photographic images of my child.
I have read this release and fully understand its contents. I am the legal parent/ legal guardian of the
participant named above and am authorized to sign this Release and Permission Slip. Parent/ Guardian
Parent/Guardian Signature: _________________________________________
Date: _____________________