Children and Student Ministries Consent and Release Form 2023-2024

Child/Student Information

School Grade

First Name

Last Name

Date of Birth

Gender

Mobile Number (no dashes, just numbers)

Mailing Address

Mailing City

Mailing Zip Code

Email Address

Health Information

Special Needs Child

Allergies?Other Medical Conditions

Insurance Company

Policy Number

Policy Holders ID#

Doctors Name

Phone(no dashes, just numbers)

Address

Emergency Contacts

Signature of Primary (type name) of parent(s) or guardian(s)

Name

Phone(no dashes or spaces)

Address

Secondary Contact

Relationship

Name

Phone #(no dashes or spaces)

Address

Release for Health Care

In the event of an emergency or non-emergency situation in which medical treatment is required as a result of participation in the activities of Children or Student Ministries and/or Countryside Covenant Church during the period of time between June 1, 2023 - May 31, 2024; every reasonable effort will be made to contact the persons listed above. If unsuccessful in contacting the persons listed, consent is given for treatment by competent medical personnel. Further, consent is given to children/youth directors or volunteers of Countryside Covenant Church to hospitalize, secure proper treatment for, and to administer an injection, anesthesia, or surgery (under recommendation of qualified medical personnel).

Consent

I accept

I decline

Signature of Primary (parent(s) or guardian(s) *

Idemnification and Release

By signing this document, you agree that you are the legal parent(s)/guardian(s) of the Child/Student listed on this form and consent to the following:

I consent to the said minor attending activities of Children or Student Ministries of Countryside Covenant Church of McPherson, KS, that are scheduled from June 1, 2023 - May 31, 2024, and which will include various modes of transportation such as bus, train, personal automobile, etc.

I/we hereby further consent to medical care and treatment being rendered or furnished to said minor in the event such circumstance should arise, and prompt notification of same will be given to the undersigned.

I/we, the undersigned, hereby agree to indemnify and hold harmless Countryside Covenant Church and any individual in his or her capacity as a board member, officer, director, trustee, pastor, counselor, or teacher from and against all claims, damages, losses, and expenses, including attorney's fees, arising out of or resulting from the participation of said minor in the activities indicated above.

Consent

I accept

I decline

Signature of Primary (type name) of (parent(s) or guardian(s) *

Covid Risk

I agree that on behalf of my child/ward that I am assuming the risk that my student may be exposed to Covid-19 while attending activities with Children or Student Ministries, and I agree for myself and my child/ward to hold Countryside Covenant Church, its employees, volunteers or agents harmless from any responsibility if they are exposed or contract the virus. I also understand that if my student is exposed to Covid-19 while riding in the van or attending an event, they may be required to quarantine or take other steps as recommended by the McPherson County Health Department, and Countryside Covenant Church will cooperate with the appropriate health official if names of attendees are requested.

Consent

Signature of Primary (type name) (parent(s) or guardian(s) *

Social Media/Website Permission

Unless notified, in writing, to the contrary, Countryside Covenant Church has permisson to use my child's name, likeness, image, voice and/or appearance, which may be embodied in any photos, videos, digital images, and the like, taken or made during any Church activities. Please note that when we post pictures on social media or the website we do not post your child's name.

I understand and agree to the above agreement. Please check the appropriate box and type your name below

I accept

I decline

Signature of Primary (type name) of (parent(s) or guardian(s) *

Relationship