2021 - 2022 Child Registration Form

MEFC CHILD REGISTRATION FORM

All minors wishing to participate in Montvale Evangelical Free Church (MEFC) activities and programs, including the church nursery, must have their parent or legal guardian complete and sign this form. Information contained within the form will be used to ensure the protection of children who participate in our programs or use our facilities. All information is considered confidential and will be treated appropriately.
CHILD INFORMATION
Child's Name *

First Name Last Name
Child's Date of Birth *

Month Day Year
Date
Check One *
Child's Gender *

Male Female
PARENT / LEGAL GUARDIAN INFORMATION
Parent / Legal Guardian Name *

First Name Last Name
Second Parent / Guardian Name

First Name Last Name
Parent Email Address(es) *
List all phone numbers where the parent / guardian can be reached *
Name, Number, Type (home, cell, work)
Other Emergency Contact
Name, Number, Relation
MEDICAL INFORMATION
Insurance Company
Insurance Company Phone
Policy Holder's Name
Policy Holder's Date of Birth
Policy Holder's ID Number
Group Number
Child's Primary Care Physician
PCP's Phone
Name of Practice
Date of Last Tetanus Shot
Preferred Hospital in Case of Emergency
MEDICAL HISTORY AND CONDITIONS
List any medical history or conditions (e.g. asthma, diabetes, seizure disorder) for the child
List any allergies (drug/medicine, food, environmental, etc.) and the severity/type of reaction
List any medications being taken
Please explain any other pertinent information about the child (i.e. physical, behavioral, emotional) that would be important for the adult leaders to know
MEDICAL TREATMENT AUTHORIZATION
I understand that in the case of a medical emergency involving my child / youth, I will be notified. However, in the event that I cannot be reached, I authorize MEFC to seek and obtain necessary medical treatment in the event my child is injured or becomes ill. This may include emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment or hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. *

Yes No
I understand that MEFC will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent / guardian. I will be liable and agree to pay all costs and expenses incurred in connection with such medical and/or dental services rendered to the minor pursuant to this authorization. *

Yes No
I agree to notify MEFC in the event of any health changes which would restrict my child or youth’s participation in any activities. I also understand the adult leaders reserve the right to restrict my child from any activity where they do not feel it is within the physical capabilities of my child / youth.

Yes No
I do hereby agree to hold MEFC, and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my/our child or property, even injury resulting in death, which I now have, my minor child has, or which may arise in the future in connection with any medical treatment deemed necessary and authorized by MEFC’s representative in his/her exercise of the terms of this Medical Treatment Authorization.
Parent / Legal Guardian Signature *

Clear
PHOTO & VIDEO CONSENT AND RELEASE
From time to time, MEFC may photograph and take video recordings of child / youth during church-related activities and programs. This release grants MEFC the right to use and re-use, publish and re-publish, and modify or alter images (photographs, digital images, video or other recordings) taken during the shoot. Use of the images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the images and release and discharge MEFC from any and all claims arising out of use of the images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
I have read the above statement and:

Yes, I fully understand and agree to its consent. No, I do not wish for my youth's photo to be used in any regard.
Parent / Legal Guardian Signature *

Clear
Parent / Legal Guardian Signature *

Clear
PARENT / LEGAL GUARDIAN CONSENT & RELEASE
This consent must be completed on behalf of all Children and Youth who participate in MEFC activities and programs.

I, the undersigned, being the parent or legal guardian of the child named in this document, do hereby consent to the participation of my child in all of the regularly scheduled activities of the Children’s and Youth ministries at Montvale Evangelical Free Church.

In consideration of MEFC allowing my child / youth named in this document to participate in children / youth ministry (Sunday School, King’s Kids, Boy’s Brigade, Events, Retreats, Mission’s Trips, etc.) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless MEFC, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child / youth participant while involved in child /youth activities and/or childcare.

I, the parent or legal guardian of this child / youth participant, grant my permission for the child / youth named in this document to participate fully in children / youth ministry activities and childcare, including trips away from church premises.

Furthermore, I, on behalf of my minor participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of the child or youth participant, including expenses incurred attendant thereto.

I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by the law of the States of New Jersey and New York and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further agree that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that I have read and understand.
Name of Child *

First Name Last Name
Name of Parent / Legal Guardian *

First Name Last Name
Parent / Legal Guardian Signature *

Clear
Date / Time
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MEFC CHILD REGISTRATION FORM

CHILD INFORMATION

PARENT / LEGAL GUARDIAN INFORMATION

MEDICAL INFORMATION

MEDICAL HISTORY AND CONDITIONS

MEDICAL TREATMENT AUTHORIZATION

PHOTO & VIDEO CONSENT AND RELEASE

PARENT / LEGAL GUARDIAN CONSENT & RELEASE