Tide Permission Form
This form is for your student to attend events being organized by the Tide Youth Ministry of Dardenne Presbyterian Church during the months of June 1, 2016 through June 30, 2017.
Student Last Name *
Your answer
Student First Name *
Your answer
Birthdate *
MM
/
DD
/
YYYY
Gender *
Grade (as of Fall 2016) *
School
What School Do you attend?
Your answer
Church
What is your home church?
Your answer
Address *
Your answer
City *
Your answer
Home Phone Number
Your answer
Student's Cell Phone
Your answer
Mother's Name
(Last, First)
Your answer
Mother's Home Phone Number
Your answer
Mother's Cell Phone Number
Your answer
Father's Name
(Last, First)
Your answer
Father's Home Phone Number
Your answer
Father's Cell Phone Number
Your answer
Emergency Contact (Other Than Parent)
(Last, First)
Your answer
Emergency Contact (Other Than Parent) Phone Number
Your answer
Insurance Information
Insurance Company *
Your answer
Policy # *
Your answer
Group # *
Your answer
Insurance Co. Phone Number *
Your answer
Physican *
Your answer
Physican Office Phone Number *
Your answer
Please list any known allergies:
Your answer
Please list any medications taken on a regular basis and what they're treating: *
Your answer
Permission
I give permission for pictures of my child taken during regular student activities to be used on promotional flyers or posted on the Tide Youth Ministries/Dardenne Presbyterian website (without student’s name attached to the picure). I am the parent or legal guardian of the student named above, a minor, and have given my consent for him/her to attend events being organized by the Tide Youth Ministry of Dardenne Presbyterian Church during the months of June 1, 2014 through June 30, 2015. Also, I give permission for the staff, volunteers, and sponsors to provide transportation for my child to any event requiring transportation. It is my understanding that this is a comprehensive permission form covering all activities related to the youth ministry of Dardenne Presbyterian Church. However this does not cover overnight trips, a separate form will be filled out for each overnight event I understand that there are inherent risks involved in any ministry or athletic event. I voluntarily elect or accept and solely assume all risk of damages and injury incurred or suffered by the student named above while attending events organized by the Church, including the event specified above. I hereby agree not to sue and release the Church, its pastors, employees, agents, volunteer workers, elders, and representatives from any and all liability, claims, damages, and costs for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement in events organized by the Church, including the event specified above. I further agree that I shall hold harmless and fully indemnify the parties hereby released from any claims, damages, and costs including attorney fees which may arise from any claim or cause of action made by me, through me or on my behalf even if caused in whole or in part by any of the parties or entities hereby released. In the event that he/she is injured and requires medical attention, I consent to any reasonable medical treatment as deemed necessary by a licensed health professional. In the event treatment is required from a licensed health professional and/or hospital personnel designated by the Church, I agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such medical care. I also agree to hold harmless and release the Church, its pastors, employees, agents, volunteer workers, elders, and representatives from any and all liability related to expenses arising from the giving of such medical care to the extent those expenses are not reimbursed by my or the student’s health insurances. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above at the time of the event specified above. I also agree to bring my child home at my expense should he or she become ill or if a student ministries staff member deems it necessary. I understand that this form does not guarantee my student a spot on any activity or trip, rather it enters them in the registration process. I also agree to forgo any money paid for a given event as refunds are only given in case of emergency cancellation (i.e. death in the family, illness). I ACKNOWLEDGE THAT I HAVE READ AND THAT I UNDERSTAND EACH AND EVERY ONE OF THE ABOVE PROVISIONS IN THIS WAIVER, CONSENT, RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT AND AGREE TO ABIDE BY THEM. *
By entering your name and initials, you (the parent) agree to accept the terms of the above document with an electronic signature. (Parent Name, Date)
Your answer
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