1 Contact Information2 Medical Information3 Acknowledgement Event You're Attending*Contact InformationStudent's Name* First Last Age*Grade*Your Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Emergency Phone*Alternate Emergency Phone Health Insurance and Medical InformationHealth Insurance Company Name*Policy #*Providing this information may speed the administration of emergency medical treatment to your child. You can also attach a copy of your health insurance card. Limitations and ConditionsCheck all that apply and add description for all checked conditions below. Allergies Physical or Mental Illness Chronic Medical Conditions Learning Diabilities Physical Disabilities Swimming Limitations Other Allergies*Physical or Mental Illnes*Chronic Medical Conditions*Learning Disabilities*Physical Disabilities*Swimming Limitations*Other*MedicationsAdult leaders must be notified of all medications possessed by the student while in church care. What, if any, medications/dosages should be taken while a child is in our care, etc.? List anyone to whom your child should not be released: Photos: By signing this form I give permission for my child’s photo to be used for advertising and promotional materials so long as it is used without identifying information. Code of Conduct: I support the Church in enforcing this code with my child. Students who fail to comply with these expectations may be sent home at parents’ expense. No possession or use of alcohol, drugs, tobacco products, weapons, fireworks, lighters, or explosives. No offensive or immodest clothing, profane language, sexual explicit material. Electronic devices may be used only in times and places allowed and in accordance with leader instructions. No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters. Participation with all group activities during event is required. Respect property, other youth, staff, and adult leaders Respect and comply with event schedules. I, the undersigned, have legal custody of the student named above, a minor. By signing this form and dropping my child off at the event I indicate that I am aware of the nature, timing, and location of the event for which I have dropped off my child. I understand and accept that plans for events may change without notice. In the event that my child should require emergency medical treatment while attending any event and the undersigned cannot be contacted, I give any adult youth leader/chaperone attending the event permission to authorize any immediate emergency medical treatment deemed necessary for my child’s health and well-being. In the event treatment is required from a physician and/or hospital or medical personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. Consent is given to transport child to hospital via ambulance or personal vehicle. I release the Church, its staff, and volunteers of any liability against personal losses of named child. I also authorize the medical provider to provide the leaders with all health and medical information necessary for them to make an informed decision as to an appropriate course of medical treatment. I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement. I also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided on this form is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home at my own expense should she/he become ill or if deemed necessary by the student ministries staff member. Consent*Typing your name on this line acknowledges consent of the statement above.Today's Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.