PVBC Student Permission Form

Pleasant View Baptist Church Student Permission Form

This form is valid from the date signed until December 31, 2020
Participant's Full Name*

First NameLast Name
Participant's Birth Date*

MonthDayYear
Participant's Phone Number
Current Grade*
Child's Allergies or medical problems
Consent

I hereby attest that I am (we are) the legal parent\guardian(s) of the above-named child and hereby consent to the child's participation in the activities and events with Pleasant View Baptist Church and the Student ministry associated with Pleasant View Baptist Church.
Transportation

I hereby grant permission as the legal parent/guardian of the above-named child that when the child is attending events with Pleasant View Baptist Church's Student Ministry they may be transported by the licensed drivers over 21 within the leadership of Pleasant View Baptist Church's Student Ministry.
Emergencies

If the above-named child requires any emergency medical treatment or procedures during the activities, I hereby consent to and authorize the leaders of Pleasant View Baptist Church's Student Ministry to make any decision and take any action to arrange for such procedures or treatments in the discretion of the activity supervisor(s). These include, but are not limited to: Attempts to contact a parent or guardian, attempts to contact emergency contacts listed below, attempts to contact student's physician, seek medical examination/treatment for injuries/condition by medical professionals.
Parent/ Guardian Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Primary E-mail*
Secondary E-mail*
Home Phone Number

Area CodePhone Number
Primary Cell Phone Number*

Area CodePhone Number
Secondary Cell Phone Number*

Area CodePhone Number
Emergency Contacts

If, in the event of a medical or other emergency, I am unable to be reached by telephone at my home or work telephone numbers listed below, I authorize the activity supervisor(s) to attempt to contact me through the emergency contacts listed below.
Emergency Contact#1 Name*

First NameLast Name
Relationship*
E-mail*
Home Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Emergency Contact#2 Name

First NameLast Name
Relationship
E-mail
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Medical Information

If, in the event of a medical emergency, we are unable to reach a parent/guardian or emergency contact and must seek professional medical examination and treatment I authorize the leaders of Pleasant View Baptist Church's Student ministry to use the provided information.
Generally, Participants Health is:

ExcellentGoodFairPoorOther
If Fair or poor, please explain
List any current medication being taken
List ALL Allergies (food/meds/pets/etc.)
List any special dietary needs
Date of last Tetanus shot
List any additional health, emotional, or other conditions of which we should be aware
Family Physician

First NameLast Name
Phone Number

Area CodePhone Number
Medical Insurance Co.
Name
Subscriber Name
Policy #
Group # (if applicable)
Photo Use Agreement

I, as the parent/guardian of the above-named child, hereby grant, voluntarily and with fullunderstanding, to Pleasant View Baptist Church, a license to the following: 1. Use and storage of my name and image, by means of digital or film photography, video photography,audio recording or other documentation, with respect to the activity, namely the Student Ministry, of Pleasant View Baptist Church. 2.Use of any stored data including my name and image in printed publications of Church. 3.Use of any stored data including my name and image in electronic publications of Church. 4.Use of any stored data including my name and image in any Web site created by or for Church for its sole benefit. 5.If I am signing this agreement on behalf of a minor child, I hereby warrant that I am the legal parent or guardian of the child and that I have the legal authority to sign this agreement on behalf of the above named child. 6.If a dispute over this agreement or any claim for damages arises, I agree to resolve the matter through a mutually acceptable alternative dispute resolution process.
I, the parent/guardian of the above-named child have carefully read the Photo Use Agreement.*

I agreeI disagree
I, the parent/guardian, hereby attest that I have carefully read this Permission to Participate, understand its contents, and agree to its terms and conditions including that any expenses incurred in necessary emergency or other medical treament will be borne solely by the student's medical coverage and/or family. I will not hold any leader or organization liable for any injury or accident.*

I agree
Date*

MonthDayYear
Parent/ Guardian Signature

Clear
Should be Empty:

Pleasant View Baptist Church Student Permission Form

Consent

Transportation

Emergencies

Emergency Contacts

Medical Information

Photo Use Agreement