NLC KIDS 2023 Parental Consent, Certification and Medical Authorization Form
Parents and legal guardians of minor children 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.
ONE FORM PER STUDENT
Student's Name
*
First Name
Last Name
Date of birth
*
/
Month
/
Day
Year
Date
Grade
*
Pre-school
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Father's Name
First Name
Last Name
Mother's Name
First Name
Last Name
Child's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Parent's Work Phone
-
Area Code
Phone Number
Parent's Cell Phone
*
-
Area Code
Phone Number
Primary Care Doctor
*
Doctor Phone
*
-
Area Code
Phone Number
Medical Insurance Provider
*
Group #
*
Policy #
*
Name of primary insured
*
First Name
Last Name
Consent and Certification
I,the undersigned, being the parent or legal guardian of the student named above,do hereby consent to the participation of my child in all of the regularly-scheduled activities of the youth or children ministries of New Life Church. This may include field trips, camp outs, swimming, boating, hiking,sporting events, and any other activities customarily associated with a church youth group or kids group. Further, I certify that my child is physically fit and adequately trained to participate in such events, including swimming,(except as noted below).
Medical Questionnaire
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 require a special diet?
*
Yes
No
If yes, please explain
Does your child have (or has ever had) any of the following:
Seizure disorders
Asthma
Heart murmur
Diabetes
Hay Fever
Kidney disease
If yes to any of the above, pleas explain
Does your child have any allergies other than medical?
*
Yes
No
If yes, please explain
Does your child ever sleepwalk?
*
Yes
No
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 that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I authorize the New Life Church Staff to make emergency medical care decisions on behalf of my child, if required by law or a health care provider I understand that the church will not be responsible for medical expenses incurred solely on the basis of this authorization. I agree to notify the church in the event of any health changes which would restrict my child’s participation in any normal youth or children’s activities. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.
Parent / Guardian name
*
First Name
Last Name
Signature date
*
-
Month
-
Day
Year
Date
Photo Release
I hereby grant permission to use any still and/or moving image (video footage, photographs, and/or audio footage) depicting the child named above, to be used on the church’s website, social media groups, or other online and/or printed publications without further consideration I acknowledge New Life Church has the right to alter the photograph(s) at its discretion. I also acknowledge that the church may choose not to use my or my child or dependent's photograph(s) at this time, but may do so at a later date, up to 2 years from the date of the photograph was taken. I also understand that once an image is posted on the website or other online platform, the image can be downloaded by any computer user, anywhere in the world. New Life Church commits to eliminating any identifying information including name and age from the publication2. I hereby waive any right I may have to inspect and/or approve the finished product or the copy wherein my child/dependent’s likeness appears, or the use of which it maybe applied. I hereby release, discharge, and agree to indemnify and hold harmless New Life Church, its officers, agents and/or designated leadership, from all claims, demands, and causes of action that I or my child/dependent have or may have by reason of this authorization or use of my child/dependent’s photographic portraits, pictures, digital images or videotapes, including any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said images or videotapes, or in processing tending towards the completion of the finished product, including, but not limited to, publication on the internet, in brochures, or any other advertisements or promotional materials.
E-Signature of Parent / Guardian
*
Submit
Should be Empty: