Parental Consent Form

School Year: 20 blank* - 20 blank*

Name of Person Completing Form*

First NameLast Name

Email (a copy of the completed form will be sent to this email address)*

example@example.com

Full Name*

Preferred Name

Gender*

MF

Address*

Street Address

Street Address Line 2

City, State, Zip Code

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Current Grade*

Family Position*

FatherLegal Guardian

Name*

Street Address (if different from participant)

City, State, Zip Code

Cell Phone*

Email Address*

example@example.com

Family Position

MotherLegal Guardian

Name

Street Address (if different from participant)

City, State, Zip Code

Cell Phone

Email Address

example@example.com

Name*

Relationship to Participant*

Cell Phone*

Name

Relationship to Participant

Cell Phone

Health Insurance Provider*

Policy Number*

Group Number*

Name of the Policy Holder*

Health Insurance Provider Phone Number*

Is the above-named participant in good health and able to participate in all activities?*

YesNo

If no, please specify limits of participation

Any allergies to food or medication?*

YesNo

If yes, please specify allergies:

Is the participant currently under a doctor's supervision for any of the following?*

Any other condition or special care need we should be aware of?*

YesNo

If yes, please describe:

Is the participant taking any prescription medications?**

YesNo

#1: Name of Medication and Dosage/Frequency

#2: Name of Medication and Dosage/Frequency

#3: Name of Medication and Dosage/Frequency

#4: Name of Medication and Dosage/Frequency

*Group leaders must be informed of any prescription medication brought by participant, with clear information as to proper use and dosage. If medication is 'as needed', participant must understand the symptoms of their condition and know when to ask for help.

Please check all over-the-counter medications you will NOT allow to be dispensed to this participant:

Date of last tetanus shot

Date

Physician Name

Physician Phone Number

MEDICAL CONSENT: As the legal guardian, if the participant is a a minor under the age of 18, I hereby attest that I have read this complete document; all information provided is complete and true. I have legal standing to make decisions which affect the rights of the above- named participant; and, I understand and consent to all terms outlined in this document. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to ministry activities and travel, understanding that some activities may pose a risk of injury. I will not hold liable Trinity on the Hill, Augusta, its employees, agents and event/group leaders for any injury, illness or property damage involving the above-named participant, no matter how caused. Whenever deemed necessary by group leaders, I authorize the calling of a doctor and/or the providing of other medical services and, unless covered by insurance, agree to pay for same. If the above-named participant is incapacitated or under age 18, I do hereby authorize group leaders as agent for the undersigned, to consent with respect to such participant to any x-ray, examination, anesthetic, medical, dental or surgical diagnosis and/or treatment, and hospital care which is deemed advisable by a state-licensed physician or surgeon.

PARENTAL CONSENT (for minor under age 18): As legal guardian of the above-named minor under the age of 18, I give my permission for him/her to be involved in the ministry program(s) of Trinity on the Hill, Augusta. I am familiar with the general goals and purposes of the program(sI understand I will be notified for any special activities and trips away from the church, including location, form of travel and cost. Should my child choose to attend such activities, I agree to send them with the appropriate clothes, personal items and money needed. Unless I have made special arrangements with a group leader, transportation to/from church or group activities, or to a common drop point for group travel, is the child and parent's responsibility. If my child needs to be sent home for any reason, including behavioral problems or medical reasons, I agree it will be at my expense.

PHOTOGRAPHY, DIGITAL, VIDEO RELEASE: I hereby grant Trinity on the Hill, Augusta, and its representatives permission to use, without

compensation or restriction, photographs, digital images and videotape images in which the participant appears, in any manner whatsoever such as, but not limited to: publication, display, advertising, slide shows, etc.

CONFIDENTIALITY: I understand that health information in this form will only be shared, as needed, with group leaders, Church staff and

medical professionals to safeguard and support the participant. This information will not be publicly disseminated or released to outside organizations. However, since it is common practice for the Church to publish a participant's address, phone number and/or birthday on the group's roster, if they actively participate in the group, I authorize the Church to publish such information on a local (or event) roster.

LIMIT OF CONSENT: The consent outlined in this Parental Consent & Medical/Liability Release, concerning my child's participation in

ministry activities, expires one (1) year from the date signed. It is my responsibility to notify the Church staff or group leaders if any

information changes or I decide to withhold consent.

TERMS OF ACCEPTANCE and SIGNATURE: I hereby attest that I have read this complete document; all information provided is complete

and true; I have legal standing to make decisions which affect the rights of the above-named participant; and, I understand and consent to

all terms outlined in this document.

Signature*

Parental Consent & Medical/Liability Release

PARTICIPANT

PARENT(S) OR LEGAL GUARDIAN(S)

EMERGENCY CONTACTS

HEALTH INSURANCE INFORMATION

MEDICAL HISTORY

MEDICAL AND PARENTAL CONSENT AND RELEASE