I give permission for

……………………………………………………

to attend the MiX and MiXXtra events
Signed ……………………………………………………………………………………...
Date …………………………………….

(parent/guardian)

In case of emergency, my contact number is:
………………………………………………………………………………………………..
Any illness/allergies we should be aware of:
………………………………………………………………………………………………...
Details of any medication we should be aware of:
………………………………………………………………………………………………...
We may take photos of the MiX to use for advertising the MiX. We
always ensure that photos conform to our photo policy which includes not putting names to photos. If you would rather not have
any photos used of your child, please contact
Jane Petrie: jane@springfieldchurch.org.uk
Address: ................................................................
................................postcode ..................
Parent/Guardian
email
...............................................................