FIFTH AVE CHRISTIAN CHURCH
Home
Who We Are
Our Team
Beliefs
Connect
Large Gatherings
Meetups
Ministries
Next Gen
>
Children
>
KidZone
Student
College
Missions
Give Online
Medical and Disciplinary Release Form
*
Indicates required field
Student Name
*
First
Last
[object Object]
Phone
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
*
Current Grade (or if summer, last grade attended)
*
Email
*
Social Media Photo Release
*
Yes
No
May we use your child's photo on our social media?
I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Fifth Avenue Christian Church’s Youth Ministry, both on and off church grounds, including the necessary transportation to and from these events and activities.
Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the child affected; (3) I cannot be personally contacted.
I further agree not to hold Fifth Avenue Christian Church or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless FACC for all claims made and liabilities assessed against them as a result of any event or activity. I release FACC and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.
Furthermore, I understand and assume the expenses of any property damage caused by my child.
Should it be necessary that my child be returned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation. I agree that FACC has complete authority in the decision to send my child home for disciplinary reasons.
By signing below, I am acknowledging that I have read through and understand the above statements and that my typed name constitutes and electronic signature.
Signature of Student
*
Date
*
Signature of Parent or Guardian
*
Date
*
In Case of Emergency Please Contact
Name
*
First
Last
Phone Number
*
Relationship to Student
*
Name
*
First
Last
Phone Number
*
Relationship to Student
*
Medical Information
Known Allergies
*
Medications
*
Medical Conditions
*
Physician
*
Phone Number
*
Insurance Company
*
Policy #
*
Submit
Home
Who We Are
Our Team
Beliefs
Connect
Large Gatherings
Meetups
Ministries
Next Gen
>
Children
>
KidZone
Student
College
Missions
Give Online