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Pittsboro United Methodist Church
Parental Permission and Medical Authorization Form 2013-2014

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MISSION TRIP PARENTAL PERMISSION
Student Name: _______________________________________________________________________________
Birth date: ___________________ Current Grade: _________ School:________________________________
Student Cell # :___________________ Student Email: _______________________________________________
Student Social Media i.e. FB, Twitter, Instagram____________________________________________________
Parent Email: __________________________ Parent Home #______________Parent Cell#_________________
I give permission for my youth (named above) to attend the Youth Mission Trip to Lexington, SC. I further give permission for
my youth to be transported to and from the event by approved adult volunteer drivers authorized by Pittsboro United Methodist
Church as outlined in the Pittsboro United Methodist Safe Sanctuaries Policy. I also give permission for my youth to