• 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


  • Primary Guardian Contact Information

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  • Secondary Guardian Contact Information

  • 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
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  • 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.
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  • Child Information

    Please fill out the questions below with your child's information.
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  • 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.

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