Christian Heritage : Family Outreach : DVD From Mom/Dad Permission Slip

Your name (Required)

Phone number (Required)

Street or post office address (Required)

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City (Required)

State: (Required)

Zip Code: (Required)

E-mail address

Incarcerated parent's name (Required)

Inmate number (Required)

Current facility (Required)

Name(s) of child(ren) (Required)

Age(s) of child(ren) (Required)

Comments/Questions:

Are you the legal guardian of child(ren)?

I authorize investigation of all statements contained in this document as may be necessary in my child(ren) receiving a DVD from Mom/Dad.

I certify that the information given herein is true and complete and that submission of this form is the same as my signing this form.

I authorize by submitting this form, a DVD will be sent to the above address.

Today's date (Required)

Questions? Please call or text Andi at 402-805-1143 or email her at andib@chne.org.

Family Outreach