Parent Authorization Form

Parents must complete this form before a student can participate in the Released Time Program named Breaktime "School Ministries of Trumbull County."

Our Mission: To present the Bible to students in a way to Engage, Encourage, Equip, and empower them to become exemplary citizens of our community.

Nearby Location Information: Students at their School may attend BREAKTIME Bible Class, if this parent permission is signed and returned. Program participation may be limited by available transportation space. Classes will be one day per week for approximately one hour during time agreed upon with school administration. Participating students will travel to a close off school campus location for classes. Feel free to contact the Program Leaders for more details.

Download this document if you want to mail in the consent form

Parental Consent Form

Parent / Guardian First name

Parent / Guardinan Last Name

Student First Name

Student Last Name

Parent / Guardian Email

Parent / Guardian Cell Phone

School

List any health concerns we need to be aware of below

Primary Contact Persons Name

Primary Contact Phone number

Secondary Contact Name

Secondary Contact Phone number

Consent Form

I, the undersigned parent/guardian of the student listed above, give permission for the student to attend the Released Time Bible Education program of School Ministries of Trumbull County (referred to as Breaktime). Students are responsible for any school assignments missed during released time classes. I may revoke consent for my student to attend the program at any time; and the program may remove any student from the program for disciplinary issues or for being disruptive. I understand that volunteers and program administrators are trained to report child abuse and neglect and concerns about self-harm.

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At times, video or photos may be taken during class or special events for promotion of the School Ministries of Trumbull County program. I give consent or do not consent to School Ministries of Trumbull County to use photos of my son/daughter. See below.

Breaktime is affiliated School Ministries.org, School Ministries Ohio.org, and Released Time.org.

I ask my student’s school to provide a copy of my student’s emergency medical card to School Ministries of Trumbull County, so that information is readily available in case of an emergency. I understand this parent consent is valid for the current school year or until revoked by me. I affirm that I am the parent or legal guardian of the student listed and I have legal authority to provide this consent, also any pertinent medical information regarding, diabetic concerns, epilepsy, food allergies, the need to carry an inhaler for asthma, or an EpiPen for anaphylaxis reactions, or other medical issues, please provide on the back of this form.

I agree to the terms & conditions

I Consent to allowing photo's or video's while in the care of released time

I DO NOT consent to any pictures or videos

Thank you for submitting

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