Central Youth Parental Consent and Release Form

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I, the parent/guardian of the student named below, hereby give my permission for my child to participate in any/all activities and programming of Central Assembly of God located in Houston, PA. I understand that my child will be participating in activities/programming either on property/in facilities owned and operated by Central Assembly of God or elsewhere and that this agreement is not limited by location or activity. I understand the general structure of the activities/programming and do not need to be informed of each and every activity. My child being in attendance signifies my permission/consent for their participation in the activity/program.
2
I agree not to hold Central Assembly of God or any of its employees, volunteers, or affiliates responsible for any expenses or injuries that my child may incur while engaged in these activities. I understand that my child is responsible for his/her behavior at all times.
I agree that in the event of an injury, Central Assembly of God personnel in charge of this activity may act on my behalf in obtaining medical treatment for my child, and I agree to take full financial responsibility for treatment. (You will be asked on the next page to indicate any permanent or temporary condition(s) that should be known about your child.)
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Student Name
First Name
Last Name
4
Birthdate
Date
Month
Day
Year
5
School and Current Grade Level
School
Current Grade Level
6
Parent/Guardian Name
First Name
Last Name
7
Phone Number
Please enter a valid phone number.
8
Parent/Guardian Email
example@example.com
9
Emergency Contact InformationComplete only if different from the Parent/Guardian Information
First Name
Last Name
10
Emergency Contact EmailComplete only if different from the Parent/Guardian Information
example@example.com
11
Emergency Contact PhoneComplete only if different from the Parent/Guardian Information
Please enter a valid phone number.
12
Relation to Student
Please Select
Please Select
Parent
Legal Guardian
Other
13
PERMANENT OR TEMPORARY CONDITION(S)

Please indicate any permanent or temporary condition(s) that should be known about your child. If none, please choose that option:
14
Does Your Child Wear Glasses?
YESNO
15
Can Your Child Swim?please select one of the options below
Please Select
Please Select
Yes, very well
Yes, but not confidently
Poor swimmer
No, not at all
16
Does your child have any of the following medical conditions:Please answer only if applicable to your child/youth
Asthma
Diabetes
Heart Condition
Allergies
Other
None
17
If you indicated your child has allergies, please list any below:
18
Please indicate any medications your child may be taking:
Huge
Large
Normal
Small
Ok
Ok
19
Please list any other conditions/limitations/needs that your child may have that we should be aware of:
Huge
Large
Normal
Small
Ok
Ok
20
PHOTO RELEASE
This parental consent form is included to both inform you and request permission for your child’s photos/images and name to be published on the Central Assembly of God public website and related social media platforms. The law requires that we ask for your permission to use photographs and information about your child. Pursuant to law, we will not release any personally identifiable information without prior written consent from you as a parent or guardian. It is our policy to keep contact information (residential addresses, e-mail addresses and phone numbers) strictly confidential at all times. We may, however, want to include photos highlighting your child’s participation on our website, social media platforms, and other publications, and seek your permission to do so.
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Please choose only ONE of the choices below:
Please Select
Please Select
I/we GRANT permission for a photo/image that includes this student without any other personal identifiers to be published on the Central Assembly of God public website or other media.
I/we GRANT permission for a photo/image and name to be published on the Central Assembly of God public website or other media.
I/we DO NOT GRANT permission for a photo/image that includes this student or any other identifiable information (as described above) to be published by, on behalf, or on the Central Assembly of God public website or other media.
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Student's Name
First Name
Last Name
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Parent/Guardian Name
First Name
Last Name
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Parent/Guardian Signature
25
Today's Date
Date
Month
Day
Year
Should be Empty: