First Reformed Church of Zeeland Medical Release & Permission Form

First Reformed Church
148 E Central Ave
Zeeland, MI 49464
616-772-9129

Student Name

Birthdate (type in date xx/xx/xxxx and click on date on the calendar)

Age

Gender

Male Female

Grade

What program(s) does your child plan to attend this school year?

Fireflies (Wednesday nights; 4-year-old preschool-1st grade) GEMS (Wednesday nights; 2nd-5th grade girls) Dusty Disciples (Wednesday nights; 2nd-5th grade boys) Middle School Youth Group (Wednesday nights) High School Youth Group (Sunday nights) Children's Worship (Sunday mornings) Nursery (Sunday mornings) Sunday School

Church involvement:

Currently attending First Reformed Church Currently attending another church Not attending church Other

T-Shirt Size (indicate youth or adult size)

Parent Email

This address will receive a confirmation email

Address

Parent/Guardian

Phone

Parent/Guardian

Phone

Secondary Emergency Contact Name

Secondary Emergency Contact Phone Number

Who is authorized to pick up your child from events?

Preferred Hospital

Medical Insurance Company

Policy #

Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Include names of medications and dosages that must be taken.

Check the following areas of concern for this student.

1. For your child's safety and our knowledge, is your student a

Good Swimmer Fair Swimmer Non-swimmer

2. Does your child have allergies to

Pollens Medications Food Insect bites No known allergies Other

Describe allergy specifics

3. Does your child suffer from, or has ever experienced, or is being treated currently, for any of the following

Asthma Epilepsy/Seizure Disorder Heart Trouble Diabetes Frequently Upset Stomach Physical Disability None

Other: please explain

Does your child have an updated tetanus shot?

Yes No

Does your child wear Glasses Contact Lenses

Should this child's activity be restricted for any reason? Please Explain

Photo Release

Do you give permission for First Reformed Church of Zeeland to use, reproduce, and/or distribute photographs, films, video, and sound recordings of your child without compensation or approval rights, for use in both printed and website materials created for purposes of promoting First Reformed Church of Zeeland.

I DO give photo permission I DO NOT give photo permission

Name of student

has my permission to attend all ministry activities sponsored by First Reformed Church.

This consenst form gives permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability aganist personal losses of named child.

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend the events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

By checking this box, I am indicating that I agree with all that is stated above

Electronic Parent Signature

*By entering my name in the above box, I am providing my electronic signature for this form

First Reformed Church of Zeeland Medical Release & Permission Form

Description

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