Girl Talk Ministry Parent/ Caregiver Intake Form

I, blanks* (Parent/Caregiver), hereby give Girl Talk Ministry   Please SelectPermissionNo Permission*  to take photographs, audios, and videos of, blank* (Child's Name), for the purpose of posting on Girl Talk Ministry’s Facebook, Instagram, Youtube, and/or website. 
 
I hereby release and discharge Girl Talk Ministry from any and all claims arising out of use of the photos, audios, and/or videos.

I, blank* (Parent/Caregivers Name), understand that Girl Talk Ministry is not held responsible for any allergic reactions that,
blanks* (Child's Name) may encounter. By signing this form, I hereby release Girl Talk Ministry and Vestibule AME Zion Church, as well as its directors or other agents from all liability or personal injuries arising from the negligence of any food consumed by my child.

I, blank* (Parent/Caregiver), hereby give   Please SelectPermissionNo permission*  for any and all medical attention to be administered to,   blank*  (Child's Name) in the event accident, injury, sickness, etc. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given.

Home Phone: blank* Work Phone:   blank* Cell Phone:   blank*   

Address:   blank*   City, State   blank*   Zip   blank*   

Insurance Company   blank*   Policy Number   blank*   

Physician:   blank* Physician Phone Number   Area Code*   Phone Number*   

Physician's Address:   blank*   

Known Allergies:   blank*   

In case of emergency, please contact the following persons:
Name Relationship Home Phone Work Phone Cell Phone
1.   blank*   
2.   blank*   
3.   blank*   

Signature*   Date*   

At times it becomes necessary to use the church- owned van to transport the girls to and from Girl Talk Ministry and Vestibule AME Zion Church. When this occurs, Girl Talk Ministry requires that a parent/guardian of the child sign the Transportation Release Consent Form that appears below.

By signing this form, I, blank* (Parent/Caregiver) hereby release Girl Talk Ministry and Vestibule AME Zion Church, as well as its directors or other agents from all liability or damages for any and all injuries arising from the negligence of any of the above while traveling to or from this activity via church van on behalf of my child, blank* (Child's Name).
 
I , blank* (Parent/Caregiver), understand that blank* (Child's Name) will be required to wear a mask in the event of having to ride the van. In order to  ensure saftey precautions are being taken due to the Coronavirus, your child will be required to wear a mask if she will be riding the van; however, if you are not comfortable with your child wearing a mask on the van she will have to be transported to Girl Talk Ministry. If your child is seen removing their mask while on the van she will not be able to ride the van any longer.