COKER KIDS NURSERY RELEASE FORM 2022-2023

Coker Kids Nursery Information/Medical/Release Form

Effective August 1, 2022- July 31, 2023
Food/Medical Allergies
Child's Name
Gender

MaleFemale
Goes by
DOB
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code
Parent/Legal Guardian's Name
Cell Phone
Email
example@example.com
Parent/Legal Guardian's Name
Cell Phone
Email
example@example.com
Emergency Contact
Relationship to child
Cell Phone
Is there any custodial information that we should be aware of? If so please list
Medical History
Please list and explain any health issues or chronic medical conditions (such as physical and/or psychological ailment, illness, limitations, disability, or condition to which your child is subject and of which the staff should be aware of, and what, if any action of protection is required on account thereof.)
Please list any
Are there any special instructions for your child?
My Child will typically attend Nursery during (please check all that apply)

Church ServicesSupport GroupsWednesday Night Bible StudySpecial Events
Consent To Treat And Release of Liability
Childs Name
has my/our consent in attending all Coker Nursery activities sponsored by Coker United Methodist Church beginning August 1, 2022 - July 31, 2023. I/We have completed the contact and the medical history information.

Effective immediately, I assume all risk and hazards and do hereby release and agree to hold harmless Coker United Methodist Church and its servants, volunteers, agents and employees from all liability for personal injury or property damage for all actions taken in good faith during church activities. Additionally, I hereby release and agree to hold harmless the church and its servants, volunteers, agents, and employees from all liability in the event that I contract COVID-19 virus during a church activity. In the event I cannot be reached or cannot communicate in an emergency, I hereby give my permission to the physician, hospital, or medical service selected by the leaders of the church to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child or myself as named above. It is understood that a conscientious effort will be made to communicate with me or the emergency contact listed before any action is taken. I accept responsibility for any and all expenses incurred from medical treatment provided. I have read this release and understand its term and execute it voluntarily and with full knowledge of its significance.
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Policies & Procedures /Photo/Media Release
I/We have received a copy of the Coker Nursery Policies and Procedures.
Please Initial
I/We understand the Coker Nursery Policy states responsibility for a child begins when properly checked into an event and ends when the child is picked up by the appropriate adult.
Please Initial
I/We understand Coker UMC from time to time produces material about its programs. I understand that my childs named on this form may be included in videos or photographs taken by church or church activities. I hereby give my consent for photographs and/or videos to be taken of my child to be used for church publicity on website, Facebook, or other social media.
I/We give permission for any videos or photographs taken of the above name child to be used on Coker UMC website, Coker Facebook and/or other social media platforms.
Please Initial
Print Name of Parent/Legal Guardian
Signature of Parent/Legal Guardian

Clear
Date

MonthDayYear
Date
Coker United Methodist Church I Family Ministries I 231 E. North Loop Rd., San Antonio, TX 78216 I 210.494. 3455
Should be Empty:

Coker Kids Nursery Information/Medical/Release Form

Medical History

Consent To Treat And Release of Liability

Policies & Procedures /Photo/Media Release