Peace Church Consent Form

This form allows Peace Church to act on behalf of the parent/guardian in the event a child should require medical, dental, surgical diagnosis, x-ray examinations, and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the state where the services are rendered, either at a doctor's office or in a hospital.

Step 1. Enter YOUR name (the parent filling out this form) in the "Parent/Guardian" field.

Step 2. This consent form covers all children in your household! Enter each child's information by selecting the "Add child" button below "Household Members" in the "Child's Information" section.

Your name *

Email address *

Parent/Guardian Name *

Address *

Phone Number *

Does your family consider Peace Church as your home church? *

Yes

Child's Information:

Household members

Please list each child you are filling this form out for.

What is your relationship to the child/children in your household? *

Father, Mother, Foster parent, etc.

Who is your child/children's primary care physician? *

What is your child/children's primary care physician's office phone number (including area code)? *

Medical Insurance Company: *

Medical Insurance Company Policy & Group Number *

Second Guardian Contact Info

Your details were collected when you filled out this form. Please include a second guardian (mother, father, other guardian, etc)

Second Guardian's Name: *

mother, father, or other guardian

Second Guardian's email address: *

Second Guardian's Phone Number: *

Emergency Contact:

In the event that a parent/guardian cannot be reached, please list the name of an individual you'd like us to contact: *

(i.e. Emergency Contact - must be different than the parents/guardians)

What is that person's relationship to your child? *

Emergency contact's phone number: *

Trusted People

Are there trusted people you would like to add to your child/children's profile?

Please indicate the names, phone numbers, and relationship to your child/children of any adults who are allowed to check in or pick up children from programming (name can be the same as Emergency Contact)

Authorizations:

Please read the paragraphs below and type your name as a representation of your signature, indicating your agreement with the terms listed.

Participation & Medical Consent *

I give my permission for my son/daughter to participate in the activities of Peace Church Children & Youth Ministries.

Should a medical emergency arise, the leaders and supervisors of the event(s) have my permission to provide basic first aid1, and a member of our safety team will determine if a higher level of care is required. The leader will contact the child’s parent/guardian to determine the best treatment option after basic first aid is provided.
If the emergency rises to a level that is determined to be life threatening, 911 will be called and the parent/guardian notified immediately.

After reasonable efforts to contact the child’s parent/guardian as well as their designated alternative emergency contact have been unsuccessful, I hereby authorize the adult representative of Peace Church Children and Youth Ministry activities to act on my behalf in the event my child should require medical, dental, surgical diagnosis, x-ray examinations, and/or hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) who is licensed to practice under the laws of the state where the services are rendered (either at a doctor's office or in a hospital). Throughout this process a representative from Peace Church will continue to attempt to contact the parent/guardian.

I agree to hold harmless and indemnify Peace Church, its employees and its volunteers against any claim or action that might arise on behalf of myself or my son/daughter other than for the willful, wanton or reckless misconduct of Peace Church, its employees or volunteers.

I and my child both understand that I may be notified and my child may be sent home at my expense before an event is over in the event of misbehavior on the part of my child.

1. OSHA states that “first aid” refers to medical attention that is usually administered immediately after the injury occurs and at the location where it occurred. It often consists of a one-time, short-term treatment and requires little technology or training to administer.

Parent/Guardian Signature:
(By typing my name, I acknowledge this as a representation of my signature, in agreement with the terms listed above.)

Media Consent: *

Media images and recordings bring life to and help tell the story of Peace Church's vibrant faith community, enhance the quality of the information we provide to our members and give visitors an idea of what to expect when they attend our church. We love to share media items gathered at our various ministry activities, events and programs in church-produced materials (including, but not limited to bulletins, posters, brochures, newsletters and other printed materials and on the church website).

Accordingly, participation in Peace Church activities implies permission for publication of any media gathered.

Parent Signature:
(By typing my name below, I acknowledge this is a representation of my signature, in agreement with the terms listed above.)

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