2022-2023 Parent Permission Form
Catawba Valley Baptist Church Student Ministries
*Valid for all CVBC Scheduled Activities for the CVBC 2022-2023 Calendar Year
Student Info:
Student Name
*
First Name
Middle Name
Last Name
Group
*
Awana (Pre-K - 6th Grade)
CVBC Students (6th Grade - 12th Grade)
Gender
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
Date
Grade
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Parent/Guardian Info:
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Emergency Contact and Medical Information
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
-
Area Code
Phone Number
Primary Physician
*
Physician Phone Number
*
-
Area Code
Phone Number
Name of Health Insurance Company
*
Type "none" if not applicable
Policy or Group Number
Health Insurance Company Phone Number
-
Area Code
Phone Number
Medical Problems/Allergies/Food Restrictions
*
Type "none" if not applicable
Medications Taking
*
Type "none" if not applicable
Activity Restrictions, if any
*
Type "none" if not applicable
Date of Last Tetanus Shot
Contact Lenses
Yes/No
Other
Term, Conditions, and Statement of Release:
READ CAREFULLY - THIS SECTION AFFECTS YOUR LEGAL RIGHTS
In exchange for participation in both off-site and on-site Student Ministry events organized by Catawba Valley Baptist Church (CVBC), and/or use of the property, facilities and/or services of CVBC, I agree for myself and (if applicable) for my child, to the following: 1. I hereby give permission for images of me or my child, captured during any Student Ministry event through audio/video/camera to be used by the church for the purposes of training and/or promotional material and publications, and I waive any rights to compensation/ownership. 2. I give my permission for CVBC Staff, its representatives, and/or volunteers to search my child’s belongings including but not limited to luggage, purses, and backpacks as deemed necessary for safety and security reasons. 3. I hereby give permission for me or my child to ride in a vehicle designated by the CVBC staff. Only adult driver’s (21 years or older), with approved driving records, will be permitted to drive. 4. In the event either I or my child causes damages, I take full financial responsibility for the damages. In addition, if early return home is warranted due to disciplinary concerns, I will provide transportation home for me and/or my child. 5. I recognize there are certain potential and inherent risks associated with participation in Student Ministry activities, and I assume full responsibility for personal injury to myself and (if applicable) my child, and further release, hold harmless, indemnify, and discharge CVBC, its staff, officers, directors, board members, volunteers, and agents for injury, loss or damage arising out of my or my child's participation in CVBC Student Ministry events, whether caused by the fault of myself, my child, CVBC, or other third parties. 6. I agree to indemnify and defend CVBC against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my child's participation in Student Ministry events. 7. In the event of an injury to me or my child during Student Ministry activities, I give my permission to CVBC or to the employees, representatives, or agents of CVBC to arrange for all necessary medical treatment, for which I shall be financially responsible. This temporary authority will begin upon signature date, and shall remain effective for one full calendar year starting upon signature date, unless sooner revoked in writing delivered to said agent(s). CVBC shall have the following powers: • The power to seek appropriate medical treatment or attention on behalf of me or my child as may be required by the circumstances, including without limitation, that of a licensed medical physician and/or a hospital, • The power to authorize medical treatment or medical procedures in an emergency situation; and • The power to make appropriate decisions regarding clothing, bodily nourishment, and shelter. 8. I hereby consent and give permission for me or my child to participate in off-site and/or on-site Student Ministry events, and agree on behalf of the above minor to all of the terms and conditions of this Agreement. By signing this Release of Liability, I represent that I have legal authority over and custody of the child mentioned above. This document is governed by the laws of the Commonwealth of Virginia, and the assumption of risk herein is intended to be as broad and inclusive as permitted by law.
I AGREE TO THE ABOVE TERMS AND CONDITIONS
*
Yes
No
I ,the Parent/Guardian, do hereby agree with the statements and terms above, and certify all the information stated to be true (Signature):
*
Clear
I ,the Parent/Guardian, do hereby agree with the statements and terms above, and certify all the information stated to be true (Print Name):
*
Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Submit
Should be Empty: