HNC KIDS: Activity Permission Form

Activity Permission Form: Medical & Liability Release

Children’s Ministries at Hillsboro Nazarene Church June 1, 2024 - Sept. 1, 2025
Child's Name*

First NameLast Name
Grade:*
2023/24 School Year
Birth Date*

MonthDayYear
Parent/Guardian Information*
Emergency Contact Information*
Confidential Medical Information
Doctor and Insurance Information:
Please list any allergies:
Please list any medications taken on a routine basis:
Please list other conditions we need to be aware of in case of an emergency:
Emergency Medical Release
I hereby give consent to any emergency medical treatment deemed necessary by the Hillsboro Nazarene Church’s appointed medical team during the above mentioned student’s involvement at events. I recognize that when my child attends events, he/she will be exposed to the physical risks involved in activities related to the events. I absolve Hillsboro Nazarene Church and any other adults connected with these activities of liability for any accident or illness which might occur. I also accept responsibility for expenses incurred through such treatment. I am not aware of any physical limitations that would hinder my child from participating at events, and my child has permission to participate. *
Transportation Release
I hereby give consent to any emergency medical treatment deemed necessary by Hillsboro Nazarene Church’s appointed transportation team and any other adults connected with transporting the above mentioned student to and from events. I absolve Hillsboro Nazarene Church and any other adults connected with transportation of liability for any accident or illness which might occur. *
Publication Release
I hereby give permission for Hillsboro Nazarene Church to use any photo or video taken during events, of my child/family in publications. I release my right to any kind of remuneration for said photos or video. *
Hereinafter, my child has permission to both travel with and participate in the activities of the Children’s Ministries of the Hillsboro Church of the Nazarene from June 1, 2023 through and including Sept. 1, 2024.
Signature*

Clear
Should be Empty:

Activity Permission Form: Medical & Liability Release

Confidential Medical Information

Emergency Medical Release

Transportation Release

Publication Release