2019-2020 First Covenant Church of Saint Paul and Family Values for Life Children and Youth Medical Release and Parental Consent Form
Thank you for entrusting us with the care and nurture of your child. For the safety and wellbeing of your child and other participants, it is important that you provide complete and accurate information. Medical information will be kept confidential.

Effective dates: September 1, 2019 to August 31, 2020. Please fill out one form for each child in your household.
Student Information
Name (first, middle, last) *
Your answer
Preferred Pronouns: *
Required
Age *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Grade *
Your answer
School *
Your answer
Child/Youth Email Address (if no email, put n/a) *
Your answer
Home Phone *
Your answer
Child/Youth Cell Phone (if no cell phone, put n/a) *
Your answer
Address *
Your answer
Parent or Guardian Information
Parent/Caregiver Name(s) *
Your answer
Relationship to Student *
Your answer
Cell Phone *
Your answer
Home/Work Phone *
Your answer
Email Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone(s) *
Your answer
Transportation
I give permission for FCC/FVFL to provide transportation to or from programming for my child. *
I give permission for my child to walk home. *
Anyone my child knows is allowed to check them out of programming. *
The following people are NOT allowed to check my child out of programming:
Your answer
Medical History
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.
Does your child have allergies to: *
Required
Please explain any allergies as needed.
Your answer
Has your child ever experienced, or is your child currently being treated for, any of the following: *
Required
Please explain any conditions noted above.
Your answer
Please list and explain any major illnesses the child experienced during the last year:
Your answer
Should this child's activities be restricted for any reason? *
If "yes" please explain below. If you want to limit your child's participation in any event, please submit your wishes in writing prior to that event.
Your answer
Behavior Guidelines and Signature
We expect each student to conform to all of these rules of conduct. No possession or use of alcohol, drugs, or tobacco. No fighting, weapons, fireworks, lighters, or explosives. No offensive or immodest clothing, no boys in girls' sleeping quarters/girls in boys' sleeping quarters on overnights. Participate in group activities, with a good attitude, being willing to "give it a try!" Respect one another, staff, and adult leaders, respect property and other guidelines.

Students who fail to comply with these expectations may be sent home at their parent/caregivers expense. This consent form gives permission to the Church and its staff to seek whatever medical attention is deemed necessary and releases FCC/FVFL and its staff from any liability against personal losses of named child.

By electronically signing below, you are indicating the child named above has your permission to attend all activities with FCC or FVFL from September 1, 2019 - August 31, 2020. You are certifying that you have legal custody of the student named above, a minor, and have given your consent for them to attend events being organized by FCC/FVFL. You understand that there are inherent risks involved with any ministry or athletic event and you 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 your child's involvement. In the event that your child become injured and requires the attention of a doctor, you 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, you agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. You also acknowledge that you will be ultimately responsible for the cost of any medical care should the cost of medical care not be reimbursed by the health insurance provider. You also agree to bring your child home at your own expense should they become ill or if deemed necessary by a ministry team member.
I give the FCC/FVFL permission to use photos of my child in displays, presentations, and publications related to church activities. *
Sign your name below, as an electronic signature certifying that you have read the above and consent. *
Your answer
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