(Other than parent)
(Other than parent)
Please provide us with additional details on any allergies
Please provide us with additional details on any maladies.
Has your child experienced any major illnesses within the last year?
Please share any reason your child's activities should be restricted.
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 the names of medications and dosages that must be taken.
I understand that while this document contains pertinent information staff can reference, it is my responsibility to ensure staff and volunteers are aware of any pertinent physical limitations, allergies, restrictions, or other medically relevant information at each event.
This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against 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 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.
I give permission for Pleasant Valley Church to take pictures/video of my child's face or distinguishing features during Ministry Events and/or Sunday Morning Services. I understand that these pictures/videos may be posted on their Social Media or used for church related uses.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
I warrant the truthfulness of the information provided in this application. Enter your first and last name:
