2017-2018 Parent Permission Form

2024-2025 Parent Permission Form

Catawba Valley Baptist Church Student Ministries
*Valid for all Catawba Valley Baptist Church sponsored activities, events, and to ride church transportation for the 2024-2025 calendar year.
Student Info:
Student Name*

First NameMiddle NameLast Name
Group*

Awana (Age 3 - 5th Grade)CVBC Students (6th Grade - 12th Grade)
Gender*
Birthdate*

MonthDayYear
Date
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Parent/Guardian Info:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Email*
example@example.com
Emergency Contact and Medical Information
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Primary Physician*
Physician Phone Number*

Area CodePhone Number
Name of Health Insurance Company*
Type "none" if not applicable
Policy or Group Number
Health Insurance Company Phone Number

Area CodePhone 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*

YesNo
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*

MonthDayYear
Date
Name*

First NameLast Name
Should be Empty:

2024-2025 Parent Permission Form

Student Info:

Parent/Guardian Info:

Emergency Contact and Medical Information

Term, Conditions, and Statement of Release: