2022-23 Jacksboro Homework Club
A Ministry of CCF of The Parish and FUMC Jacksboro
Homework Club Member Information
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First Name
Last Name
Grade Entering THIS School Year?
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Please Select
Kindergarten
1st
2nd
3rd
4th
5th
Are there any dietary issues we need to be aware of?
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Are there any medical issues/conditions we need to be aware of?
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Parent/Guardian Information
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First Name
Last Name
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Phone Number
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Please enter a valid phone number.
Relationship to Child?
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Students Age:
Type a label
Students Teacher:
Type a label
What areas and/or subjects is your child needing to work on specifically?
Please list all persons authorized to pick up your child in your absence. (Please note a photo ID and the Issued Parental Pick-Up Badge are both required).
Emergency Contact #1
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Emergency Contact #2 (Must Be Different)
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
I, the undersigned parent or guardian, do hereby attest that all the information on this form concerning my child/dependent is the most current available for my child (the “Participant”). I give my permission for the Participant to participate in the activities of The Homework Club, a ministry of The Parish of Jacksboro and Jacksboro, TX First United Methodist Church. This includes all sponsored activities on or off the premises of The Parish and/or FUMC Jacksboro, including any and all activities involving travel. This permission shall remain in effect until one year after the date signed, unless terminated in writing. I hereby authorize The Parish of Jacksboro and FUMC Jacksboro staff to administer the medications as listed above. In order for my child to receive necessary medical treatment from medical staff and/or physicians in a medical clinic or hospital in case of illness or injury, I hereby consent to and authorize the ministry staff to obtain and consent to medical treatment for such illness or injury during the activity or activities of FUMC Jacksboro and The Parish of Jacksboro. It is understood that this authorization and consent is given in advance of any specific diagnosis or treatment and is given to encourage those persons who have temporary custody of the Participant, in my absence, and medical staff to exercise their best judgment as to the requirements of such diagnosis or said medical treatment. This medical consent will remain effective until one year after date signed unless terminated in writing. I understand that any and all medical expenses incurred are my responsibility.
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I Agree
I Do Not Agree
I hereby give my permission for the Participant to be transported in any vehicle designated by any ministry leader designated by The Parish of Jacksboro and/or FUMC Jacksboro, and in whose care the Participant has been entrusted while attending and participating in an activity or activities of FUMC Jacksboro, following all Ministry Safe Guidelines.
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I Agree
I Do Not Agree
I hereby grant permission to The Parish of Jacksboro and/or First United Methodist Church of Jacksboro, TX to use any still and/or moving image (video footage, photographs, and/or audio footage) depicting myself and/or dependents on the church’s website, social media groups, or other online and/or printed publications without further consideration. I acknowledge the 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. The church commits to eliminating any identifying information including name and age from the publication. 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 may be applied. I hereby release, discharge, and agree to indemnify and hold harmless The Parish of Jacksboro and/or FUMC Jacksboro, 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.
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I Agree
I Do Not Agree
Parent of Guardian Signature
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Clear
Date
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Month
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Day
Year
Date
Submit
Should be Empty: