PCH Students Early Release WeServe at Salvation Army Parental Consent to Treat/Waiver

PCH Students WeServe at Salvation Army Parental Consent to Treat/Waiver

WeServe at the Salvation Army of Lakeland at 2626 Kathleen Rd. after Early Release on Friday, September 4th. We will meet and depart after middle school early release between 1:45 and 2:00 p.m. and plan to return by 5:30 p.m. Unless otherwise informed, students should bring a change of clothes for outside work as well as money for Chick-fil-A after serving.
Student and Parent Information
Student Name

First NameLast Name
Student Phone
Please enter a valid phone number.Format: (000) 000-0000.
Grade Completed
Does your child plan to submit these hours for Community Service?
Parent Name

First NameLast Name
Parent Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent Email
example@example.com
Parent Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Consent and Release Initials
Parent Initial
CONSENT: I am the parent and legal guardian of the minor child named above. I hereby give permission for my child to attend WeServe at the Lakeland Salvation Army and authorize Presbyterian Church in the Highlands, Inc. ("PCH") to furnish necessary transportation to and from this destination and other trip excursions. I understand that transportation may be provided via vehicles owned and operated by PCH or by vehicles owned and operated by adult volunteers for PCH.
Parent Initial
RELEASE: In consideration of my child being able to participate in the above described activity, I hereby release and agree to hold harmless PCH and its officers, directors, employees, administrators, and agents, including, without limitation, any PCH volunteers, from any and all liability, claims, causes of action, damages and demands whatsoever, including without limitation, any and all claims or causes of action for personal injury, sickness, or death which may be incurred by me or my child resulting from my child's participation in above described activity, including, without limitation, transportation to and from Beth-El and other local excursions.
Parent Initial
EMERGENCY AUTHORIZATION: I hereby authorize and appoint Jared Edgar and/or other adult leaders of PCH in whose care my minor child has been entrusted, to arrange for and consent to any emergency or ordinary and necessary medical care or treatment, for my said child as a result of any accident or illness in the event I cannot be located or contacted by the medical treatment provider. I understand and agree that I shall be liable for all costs and expenses incurred in connection with such medical care or treatment rendered to my said child pursuant to this authorization.
Parent Initial
DISCIPLINE: I agree that if the subject of this release has to return home for severe discipline violations, it will be at my/our expense.
Parent Initial
PHOTO & VIDEO: I/We consent to the use of any video images or photographs (digital or conventional) that may be taken of the subject of this release during the event to be used, distributed, or shown as Presbyterian Church in the Highlands sees fit.
Parent/Guardian Signature
Parent/Guardian Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PCH Students WeServe at Salvation Army Parental Consent to Treat/Waiver

Student and Parent Information

Consent and Release Initials

Parent/Guardian Signature