Parental Consent Form

Parental Consent Form

Parents and legal guardians of children or youth (minors) are asked to complete this form. The information requested is designed to assist the church in providing for the safety of minors during Church-Sponsored activities.
Minor's Name

First Name Last Name
Minor's Date of Birth

Month Day Year
Date
Father's Name

First Name Last Name
Mother's Name

First Name Last Name
Minor's (Household) Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Family Doctor (Minor's Physician)

First Name Last Name
Doctor's Phone Number
Please enter a valid phone number.
Medical Record Number
Consent and Certification

I, the undersigned, being the parent or legal guardian of the minor named above, do hereby consent to the participation of my child in all the regularly scheduled activities of Life Center Church including field trips, campouts, swimming, beach trips, boating, hiking, sporting events, sleepovers, and any other activities customarily associated with the church. Furthermore, I certify that my child is physically fit and adequately trained to participate in such events, including swimming, except as noted below.
Is your child presently being treated for an injury or sickness or taking any form of medication for any reason?

Yes No
If "yes," please explain.
Is your child allergic to any type of medication?

Yes No
If "yes," please explain.
Does your child require a special diet?

Yes No
If "yes," please explain.
Does your child have (or has ever had) any of the following:

Seizure Disorders Diabetes Asthma Hay Fever Heart Murmur Kidney Disease EpiPen
If "yes," please explain.
Does your child have any allergies other than medical (do they need an EpiPen)?

Yes No
If "yes," please explain.
Does your child ever sleep walk or have nightmares?

Yes No
If "yes," please explain.
Can your child swim?

Yes No
Does your child have any physical handicap or illness which would prevent him/her from participating in normal rigorous activity?

Yes No
If "yes," please explain.
Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency involving my child. However, in the event I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child in injured or becomes ill. I understand that Life Center Church will not be responsibile for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian.

I agree to notify Life Center Church in the event of any health changes which would restrict my child's participation in any normal church activity. I also understand that the adult supervisor reserves the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

Photo/Image Release

I understand that photos, video, and/or audio footage will be taken during church events/activities. I understand that these images may be used in future publications, promotional material (website, Facebook, Instagram, etc.) for Life Center Church. Any personal information about my child will be limited to the outlines set in the Model Release & Authorization Policy (listed below).

Model Release & Authorization Policy

I hereby give permission to Life Center Church the irrevocable right to use images in any media form, including composite or distorted representations, for advertising, trade, or any lawful purpose. I further waive any right to inspect or approve the finished product, including written copy, created in connection with these images.
Signature

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