2017 FVCC STUDENT MINISTRY RELEASE FORM

2017 FVCC STUDENT MINISTRY RELEASE FORM

Parents:

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Fox Valley Christian Church Student Ministry in 2017, both on and off church grounds, including the necessary transportation to and from these events and activities.

Student Name (required)

Address (required)

Student Email (required)

Student Cell Number
Okay to text?

Grade (required)

Waiver

I hereby release Fox Valley Christian Church, its staff and sponsors from responsibility and liability for any injury or illness that my child may sustain during events and activities of Fox Valley Christian Church Student Ministry both on and off grounds. In the event of a emergency, I hereby authorize an adult leader of Fox Valley Christian Church Student Ministry, as an agent for me, to consent to an X-ray examination, medical, dental, surgical diagnosis, treatment and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice in the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I expect to be contacted immediately.

Disciplinary

I hereby authorize the staff and sponsors of Fox Valley Christian Church to enforce rules and expectations for events and activities for listed student. These rules and expectations are in keeping with the desire to maintain a consistent and safe environment for all students participating in said events and activities throughout including travel and overnight accommodations if necessary. I understand that as a parent/legal guardian, I may be contacted regarding listed student’s behavior that does not meet the expectations of Fox Valley Christian Church and may be, in some cases, required to provide transportation for my student home from an event.

Medical

Health Insurance Company (required)

Policy Number (required)

No medication, neither prescription, nor over the counter, will be given without the written permission of the parent or Guardian.

All Prescription medication must be in the original container, labeled with the student’s name, name of the medication, current dosage and time taken, physician’s name and pharmacy name. All over the counter medication must be in the original container, labeled with the student’s name, dosage, time, and purpose for which it is given. All medication will be collected prior to any trip.

Allergies | Medications | Other Concerns

OVER THE COUNTER MEDICATION:

The following over the counter medications are supplied. They may be administered as deemed necessary by the adult sponsors, unless otherwise advised. Please cross out with a (X) any you would not want administered. Supplies would be generic.

AspirinSwim Ear DropsCampho PheniqueIbuprofenSudafedMidolAcetainophenRobitussinAntibiotic OintmentThroat LozengesVisineMaalox

I give the stated permissions:

Parent/Guardian Name (required)

Parent/Guardian Email (required)

Emergency Contact Number (required)

Second Emergency Contact Number

I hereby give my permission for myself or my child to participate in an activity organized by Fox Valley Christian Church. I hereby release, hold harmless and absolve Fox Valley Christian Church, their staff, sponsors, vendors and all others who have participated in the planning, organizing, and implementing of the activity, be the individuals or organizations, singly or collectively, from responsibility and liability for any illness, injury, misadventure, harm, loss or inconvenience suffered or sustained as a result of the participation in the activity. I understand that in the event I or my child requires medical treatment while engaged in the activity, reasonable efforts will be made to contact my designated emergency contacts; however, if they cannot be reached, I hereby consent and give my permission to the Fox Valley Christian Church staff or any adult counselor acting on behalf of Fox Valley Christian Church with respect to the activity, to consent to any X-ray examination, medical, dental or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either as an outpatient or in any hospital. To the best of my knowledge, I have listed above all my child’s medical allergies, medications being taken, medical problems and other pertinent information. Finally, I agree that Fox Valley Christian Church may tape or photograph my child and record his or her voice during their participation in the activity. I agree that Fox Valley Christian Church will be able to use them, in whole or in part, whether in original or modified form in any manner or media, including without limitation, for the purpose of advertising, promoting, and publicizing Fox Valley Christian Church, whether during the activity or thereafter. I hereby release and discharge Fox Valley Christian Church and all affiliated entities from any and all claims, demands, or causes of action that I have in connection with the use and exercise of the rights granted in this release.

Electronic Signature of Parent/Guardian (required)

I give the above stated permissions

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