Covenant Presbyterian Church Release Form

Child/Youth

Please complete a separate Web Waiver form for each child or youth in your care.

Child's Name*

Birth Date*

Preferred Name

Please list nickname or chosen name by which the child would like to be referred.

Grade*

School

Emergency Contact Information

Mailing Address

Primary Home/Mailing Address*

Primary Contact - Parent/Guardian Information

Parent/Guardian Name*

Email*

Phone Number*

Additional Parent/Guardian Information

Parent/Guardian Name

Email

Phone Number

Additional Emergency Contact Information

Emergency Contact Name

Relationship

Phone Number

Medical Release

Insurance Carrier

Policy #

Preferred Physician

Phone

Preferred Dentist

Phone

Current Medications

name, dosage, instructions

Additional Medical Conditions

Please list any allergies, medical, or behavioral/learning considerations, or recent surgeries

Special Dietary Requirements

indicate special dietary requirements for your child - diabetic, vegetarian, vegan, gluten free, food intolerances, etc

I, the parent/guardian of the above named child, hereby authorize the Adult Leadership of Covenant Presbyterian Church, as agents of the undersigned, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by the medical staff of a licensed hospital. Such diagnosis or treatment may be rendered at office of said physician or at said hospital. The undersigned shall be liable and agree/s to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Medical Release Agreement

Media Release

I give my permission for the display of media (photos, videos, etc.) of the above named child to appear on the Covenant Presbyterian Church Website.

I give my permission for the display of media (photos, videos, etc.) of the above named child to appear on Church Social Media Pages. Names will not be used.

Travel Release

The above named child has my permission to attend events sponsored by Covenant Presbyterian Church, which are to be held off the church grounds with the understanding that the function will have appropriate adult supervision. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Covenant.

Travel Release Agreement

Other

Anything else we should know about your child?

Electronic Signature and Acknowledgement

Enter the date and your full name to acknowledge your electronic signature of this document.

Date*

Your Full Name*

Your Electronic Signature*

This form will remain on file in Web Waiver and in the church office for the current school year. Please inform us if there are any pertinent changes.

Thank you!