Parent/Guardian Information:
Emergency Contact Information (if other than above parent/guardians)
(For an event and/or overnight event)
Is the student currently on any current medication e.g. antibiotics etc.? If so, we will need you to fill out a medication chart. (Please contact Leader to receive form)
Over-the-Counter Medication Permission
Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?
Consent and Certification
The undersigned does hereby give permission for my child, ("Participant"), to attend and participate in any Four Mile Run Christian Church student ministry activities, events, and childcare during the period of January 1, 2019 - December 31, 2019.
LIABILITY RELEASE
In consideration of Four Mile Run Christian Church allowing the Participant to participate in student ministry (Events and Activities on-site and off-site) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Four Mile Run Christian Church, its pastors, directors, employees, volunteers and teachers (collectively herein the "Church") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/student activities and childcare. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in student ministry activities and childcare, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
MEDICAL TREATMENT PERMISSION
I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment or hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned Participant pursuant to this authorization.
By entering your name in the "signature" box below, you affirm your identity in the "parent/guardian" box above and agree to be legally bound by your digital signature.