Dear Parents,

For your child’s safety, CCIC Children’s Ministry has decided to not allow elementary children (1st-5th grade) to self-dismiss from any of our programs unless parents/guardians give their permissions to do so.  Therefore, please submit the following form if you want to authorize your child(ren) to self-dismiss from any of our program(s). If your child is to be picked up by a teen, you need to submit this form too.

Children who have been authorized to self-dismiss will have a “Self-Dismiss Authorized” note printed on their Saturday AWANA and Sunday program name labels and receive a sticker “Self-Dismiss Authorized” to put on their Friday AWANA name badges.

Those who do not submit this form, please be prompt to pick up your child(ren) at the following venues:

  • Sunday 1st service at 10:30am from classrooms (refer your pick up slip)
  • Sunday 2nd service at 12:00pm from classrooms (refer your pick up slip)
  • Friday AWANA at 9:25pm from 1st Floor
  • Saturday AWANA at 8:55pm from Fireside

Please present your pick up slip (little label printed from the computer) to the teacher/leader in charge of the program/class upon pick up.

Note: It’s compulsory for parents to pick up their preschoolers (5 years old and below) from our programs including AWANA Sparks 5 years old. No self-dismiss option for preschoolers.

Parents have to provide a note to the teacher/leader in charge every time whenever a sibling/teen is assigned to pick up their preschoolers.

Thanks for your cooperation.

CCIC Children’s Ministry

Permission to Self-Dismiss Form

Without prior permission from parents/guardians, it is CCIC Children’s Ministry’s policy to not allow elementary children (1st-5th grade) to self-dismiss from any of our programs. By completing and signing below, you authorize The Church (CCIC) to allow your child(ren) to self-dismiss from the program(s) below, without being picked up by a parent, guardian, or other authorized adult (above 18).

I, with the following name as the parent/guardian,

Check box:

I agree (by checking this box, I recognize that this is equivalent to my legal signature) to give permission for my child(ren) listed below to self-dismiss from the following program(s):

Parent/Guardian's Name 家长/监护人:
Parent/Guardian's E-mail 家长/监护人电邮:
1st Child 第一小孩:
Grade (1):
2nd Child 第二小孩:
Grade (2):
3rd Child 第三小孩:
Grade (3):
Check the box ✓:

I UNDERSTAND AND DO HEREBY AGREE TO ASSUME ALL OF THE RISKS AND OTHER RELATED RISKS WHICH MAY BE ENCOUNTERED BY MY CHILD(REN) FOR ALLOWING HIM/HER/THEM TO SELF-DISMISS FROM THE ABOVE PROGRAM(S).

I agree that I hereby hold harmless and waive any and all claims against Chinese Church in Christ (CCIC), its staff, and leaders for any accident, bodily or personal injury, damage to or loss or theft of any property, illness, or death of any person, including without limitation demands, liabilities, damages, judgments, losses, costs, expenses and/or penalties, including attorneys’ and consultants’ fee and disbursements, which arise out of allowing my child(ren) to self-dismiss from the above program(s).

I further state that I HAVE CAREFULLY READ THE FORGOING RELEASE AND KNOWN THE CONTENTS THEREOF AND IS SIGNING THIS RELEASE AS AN ACT OF MY OWN FREE WILL. This is a legally binding agreement, which I have read and understand.

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