CCLM Youth Waiver 2024-2025

Annual CCLM Youth Waiver

Hey, parents! Thanks for filling out this form. It only needs to be filled out once per school year. Please note that “Parent/Guardian 1” you will be sent a copy of these responses at the email provided.
Student Name*

First NameLast Name
MaleFemale
Student Birthday*

MonthDayYear
Date
Student Phone Number (if applicable)
Please enter a valid phone number.
Student Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Grade 2024-2025*
Student’s School*
Parent/Guardian Name 1*

First NameLast Name
Relationship to Student*
Parent/Guardian 1 Number*
Please enter a valid phone number.
Parent/Guardian 1 Email*
example@example.com
Parent/Guardian Name 2

First NameLast Name
Relationship to Student
Parent/Guardian 2 Number
Please enter a valid phone number.
Parent/Guardian 2 Email
example@example.com
LIABILITY RELEASE

Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parents or guardians agree to assume and accept all risks and hazards inherent in church related activities. They also agree not to hold Calvary Chapel La Mirada or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release.

I/We also understand that if there are any disciplinary problems with the above named child, it will be our responsibility to pick up our child at the site of the event and they will not be eligible for future events without specific approval of the Calvary Chapel La Mirada leadership.
Parent/Guardian Signature*

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MEDICAL RELEASE

I/We, the undersigned, parent(s)/Guardians(s) of the child named above on this consent form, do hereby authorize Calvary Chapel La Mirada, it’s staff or representatives, as agent(s) for the undersigned to consent to a X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care that is deemed advisable by, and is to be rendered under the general supervision of any physician and surgeon licensed under the provisions of the Medicine Practice Act on the Medical Staff of any Hospital or medical clinic whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment of hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable.

The authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California (allows Parent(s) or Guardian(s) to authorize any adult to consent to medical or dental treatment as stated in the above paragraphs).

This authorization shall remain effective from June 1, 2024 through May 31, 2025, unless sooner revoked in writing delivered to said agent(s)
Parent/Guardian Signature*

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HEALTH INFORMATION
Please list any symptoms your student commonly experiences. This can include but is not limited to migraines, hay fever, seizures, bed wetting, or any other symptoms that would be helpful to know in the case of sickness and emergency.
Has your child had any of the following? Check all that apply.

Chicken PoxMeaslesGerman MeaslesMumpsAsthmaDiabetesOther
Does your child struggle with any mental illnesses? If so, please list below.
Have any of the above mental illnesses been addressed by a therapist or counselor at any time?

YesNo
Are there any health factors that would make it advisable for your child to follow a limited program of activity at youth events this year? If so, please explain.
Emergency Contact*

First NameLast Name
Relationship to Student*
Emergency Contact Number*
Please enter a valid phone number.
In the event of a minor illness (such as cold or headache), do you authorize the Leadership of Calvary Chapel La Mirada to give your child common remedies such as Tylenol, cough medicine, etc., in dosages appropriate for his/her age?*

YesNo
Please list any allergies below.
Insurance Company Name*
Insurance Phone Number*
Please enter a valid phone number.
Name of Insured*

First NameLast Name
Student’s Primary Care Physician*

First NameLast Name
Policy #*
Should be Empty:

Annual CCLM Youth Waiver