FCC Parent Consent form SUPERSTART
Parent consent and Medical form
Participant's Name
Your answer
Birthdate
Your answer
Address
Your answer
Parent(s) Name(s)
Your answer
Phone #
Your answer
Emergency Contact Name and Number
Your answer
Church you attend most
Your answer
Food Allergies
Your answer
Special considerations or restrictions
Your answer
My child has my permission to participate in SuperStart. I understand that participation in this event is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I release First Christian Church, all employees, volunteers and related parties from any and all claims or liability arising out of this participation. (Type Name)
Your answer
In case of emergency involving my child, I understand that every effort will be made to contact me. In the event I cannot be reached, I hereby give permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery or injections of medication for my child. Medical providers are authorized to disclose to the adult in charge examination findings, test results, and treatment for purposes of medical evaluation of the participant, follow-up and communication with the participant's parents or guardian, and/or determination of the ability to continue in the program activities. ( Please type name)
Insurance Company
Your answer
Policy #
Your answer
Participant's Name (will need to sign form before we leave)
Your answer
Parent's Name (will need to sign form before we leave)
Your answer
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