Emergency Contact Information
Medical/Health Insurance Care Information
This parental consent form is to both inform you and to request permission for your student's photo/image and/or name to be published on the church’s website and/or social media sites.
As you are aware, there are potential dangers associated with the posting of personally identifiable information on a website and social media sites such as Facebook. Global access to the Internet does not allow us to control who may access such information. These dangers have always existed; however, we as a church want to celebrate your child and his/her involvement with our congregation. As such, we are asking for your permission to publish information about your child.
We will not release any personally identifiable information without prior written consent from you as parent or guardian.
If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the church and such rescission will take effect upon notification.
The undersigned(s) being the lawful guardian(s) of the above children hereby consents to the participation of my child in all activities, events, trips and programming sponsored by or related to the PMBC Children’s, Youth and Young Adult Ministry.
The undersigned hereby further authorize(s) any of the staff, employees, agents and representatives of PMBC to provide for, approve and authorize any health care at any hospital, emergency room, doctor's office or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such healthcare; review and if necessary disclose the contents of any medical records; execute any consent form required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child. Healthcare shall include but not be limited to the administration of anesthesia, X-ray, examination, performance of operations, diagnostic and other procedures.
If there is no medical emergency, PMBC representative/event organizer/chaperone will first use reasonable efforts to contact the guardian(s) before administering or authorizing any treatment.
Notwithstanding other provisions in this Consent Form, PMBC shall not have the authority to withhold or withdraw life-sustaining procedures for any participant.
The undersigned assume(s) all risk of injury or harm to the child associated with participation in the activity and agree(s) to release, indemnify, defend and forever discharge PMBC and its staff, employees and agents (collectively "PMBC Children Youth and Young Adult Ministry") of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action (collectively the "Claims") in respect of death, injury, loss or damage to the child or by the child, howsoever caused, arising or to arise by reason of or during the child's participation in the activity, event, trip or programming.
This Consent Form may be revoked at any time before the expiration date with written notice to PMBC.
Please follow this link to pay before proceeding with submission:
Youth Explosion Payment