Peace Church Medical Consent Form

Peace Church Medical Consent Form
This document allows Peace Church to act on behalf of the parent/guardian in the event the child should require medical, dental, surgical diagnosis, x-ray examinations, and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the state where the services are rendered, either at a doctor's office or in a hospital.

Also included is our media policy, which you can opt-out of by emailing office@peacechurch.cc if you so choose.

Please fill out one consent form per child per ministry year.

Valid August 2020 - August 2021
Name of Child *

First Name Last Name
What Ministry does your child participate in? *

Brave Girls Bold Boys 5th & 6th Grade Youth Group Junior High Youth Group High School Youth Group
Primary Guardian Contact Information
Name *

First Name Last Name
What is the primary guardian's relationship to the child? *
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Guardian Contact Information
Name

First Name Last Name
What is the secondary guardian's relationship to the child?
Email
example@example.com
Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Contact Information

In the event that a parent/guardian cannot be reached, please list the name of an individual you'd like us to contact
Name *

First Name Last Name
Contact's relationship to child *
Phone Number *

Area Code Phone Number
Does your family consider Peace Church to be your church home? *

Yes No
Name of church you consider home
If you do not have a church home, please indicate with N/A
Trusted People

Please let us know if there are other people (other than the child's guardian(s) listed above) that are allowed to check children in or pick children up from programming.
Trusted Person's Name

First Name Last Name
Trusted Person's Phone Number

Area Code Phone Number
Are there other Trusted People you would like to add?

Yes No
Trusted Person (2)'s Name

First Name Last Name
Trusted Person (2)'s Phone Number

Area Code Phone Number
Trusted Person (3)'s Name

First Name Last Name
Trusted Person (3)'s Phone Number

Area Code Phone Number
Child Information

Please fill out the questions below with your child's information.
Does your child have his/her own email and/or phone number *

No Yes
Child's Phone Number

Area Code Phone Number
Child's Email
example@example.com
Child's Address (if different from your own)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthdate *

Month Day Year
Gender *

Male Female
Grade *

K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
School Child Attends *
T-Shirt Size *

Child Small Child Medium Child Large Child x-Large Small Medium Large X-Large XX-Large XXX-Large
Medical Notes
(i.e. allergies to both food and medications, medical conditions and current medications, both prescription and over the counter)
Is there anything else you would like us to know about your child?
(i.e. Past medical history, anything relevant to your child's attendance in Peace Church's ministries)
Date of last Tetanus shot *
If you choose not to vaccinate, please indicate.
Who is your child's primary care physician? *
Primary care physician phone number *

Area Code Phone Number
Medical Insurance Company *
Medical Insurance Company Policy & Group Number *
Authorizations

Please read the paragraphs below and type your name as a representation of your signature, indicating your agreement with the terms listed.
Participation & Medical Treatment Consent: *
I give my permission for my son/daughter to participate in the activities of Peace Church Children & Youth Ministries during the calendar year of August 2020 - August 2021.

Should an emergency arise, the leaders and supervisors of the event(s) have my permission to seek and obtain any necessary medical care for my son/daughter.

Therefore, I hereby authorize the adult representative of Peace Church youth activities to act on my behalf in the event my child should require medical, dental, surgical diagnosis, x-ray examinations and/or hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) who is licensed to practice under the laws of the state where the services are rendered (either at a doctor's office or in a hospital). I expect to be contacted as soon as possible.

I agree to hold harmless and indemnify Peace Church, its employees and its volunteers against any claim or action that might arise on behalf of myself or my son/daughter other than for the willful, wanton or reckless misconduct of Peace Church, its employees or volunteers.

I and my child both understand that I may be notified and my child may be sent home at my expense before an event is over in the event of misbehavior on the part of my child.
Media Consent: *
Media images and recordings bring life to and help tell the story of Peace Church's vibrant faith community, enhance the quality of the information we provide to our members and give visitors an idea of what to expect when they attend our church. We love to share media items gathered at our various ministry activities, events and programs in church-produced materials (including, but not limited to bulletins, posters, brochures, newsletters and other printed materials and on the church website).

Accordingly, participation in Peace Church activities implies permission for publication of any media gathered.
COVID19 Policy: *

In light of the COVID19 Pandemic, I agree to not bring my child if he/she is exhibiting any flu-like symptoms.
Parent/Guardian Signature: (By typing my name below, I acknowledge this as a representation of my signature, in agreement with the terms listed above.) *

Clear
Should be Empty:

Peace Church Medical Consent Form

Primary Guardian Contact Information

Secondary Guardian Contact Information

Emergency Contact Information

Trusted People

Child Information

Authorizations