Children's Ministry Screening Form

CHILDREN'S MINISTRY SCREENING FORM
St. Michael's is excited to partner with your family in your children's faith formation! Please complete the form below to participate in in-person Children's Ministry offerings.

Visit St. Michael's website for details on COVID-19 safety and more.

Outdoor Children's Chapel is multi-age (toddler thru elementary) and will be offered at 9:00 am

Parents/caregivers are asked to assist with limiting contact:
1. Complete this form online or in-person.
2. Ensure children have used the restroom (or have a clean diaper) and have washed their hands upon arrival.
3. Check in with the staff/volunteer responsible for attendance when dropping children off.
4. Enjoy worship! KidMin staff and volunteers will be the only adults permitted in the outdoor classroom space and playground.
For questions contact becky@stmbts.org
CHILD'S INFORMATION
Last Name *
First Name *
Birthday (mm/dd/yyyy) *
Grade (if applicable) *
Medical Concerns/Special Accomodations

Add a Sibling
Sibling 1 Last Name
Sibling 1 First Name
Sibling 1 Birthday (mm/dd/yyyy)
Sibling 1 Grade (if applicable)
Sibling 1 Medical Concerns/Special Accomodations

Add a 2nd Sibling
Sibling 2 Last Name
Sibling 2 First Name
Sibling 2 Birthday (mm/dd/yyyy)
Sibling 2 Grade (if applicable)
Sibling 2 Medical Concerns/Special Accomodations

Add a 3rd Sibling
Sibling 3 Last Name
Sibling 3 First Name
Sibling 3 Birthday (mm/dd/yyyy)
Sibling 3 Grade (if applicable)
Sibling 3 Medical Concerns/Special Accomodations

PARENT/GUARDIAN INFORMATION
Parent/Caregiver Name *
First and Last
Contact Phone *

Area Code Phone Number
Email *

WAIVERS
Medical Symptoms

Do you or your child(ren) have any sudden loss of taste or smell; fever or chills; unexplained headache; unexplained muscle aches or pains; unexplained fatigue; respiratory symptoms including cough, shortness of breath, congestion or runny nose (not due to hay fever) or difficulty breathing; or any diarrhea, nausea or vomitting?
Contact with COVID-19

Have you our your child(ren) had contact with someone with a confirmed diagnosis of COVID-19, or under investigation for COVD-19, or ill with respiratory illness within the last 14 days?
Episcopal Diocese of San Diego Medical Release and Waiver of Liability

I hereby release the Episcopal Diocese of San Diego, and St. Michael’s by-the-Sea Episcopal Church, its directors, officers, employees and volunteers from responsibility and liability for any injury or illness that my child/youth, OR I as an adult participant may sustain during this activity. In the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, 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 at a doctor’s office or in any hospital. I expect to be contacted as soon as possible. The medical information stated above is true and accurate to the best of my knowledge and belief.
Medical Symptoms? *

Yes. No.
Contact with COVID-19? *

Yes. No.
Medical Waiver *

Yes, I accept this waiver of liability. No, I do NOT accept this waiver of liability.
Date (mm/dd/yyyy) *
Signature *

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