Parental Consent & Liability Form

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Armstrong Chapel United Methodist Church Parental Consent and Liability Release Form Name: ______________________________________________M/F ___ Age: _____ Birthdate: ______________ Address: _________________________________________________________Phone: _____________________ City/State/ZIP: _______________________________________________ SSN: ____________________________ School: ________________________________________________________________________ Grade: _______ Father's/Mother's Work Phone Numbers: __________________________ & __________________________ Father's/Mother's Home Phone Numbers: __________________________ & __________________________ Father's/Mother's Cell Phone Numbers: __________________________ & __________________________ In event of emergency, if parent is not available, name of relative: __________________________________ Phone: _____________________________ Relationship: _________________________________ IF THE PARTICIPANT HAS NOT ATTAINED 18 YEARS OF AGE: To Whom It May Concern:

• As the parent(s) or legal guardian(s) of this participant, we (I) hereby grant our (my) permission for him/her to participate fully in the authorized activities (as specified by each individual activity permission form), including transportation related to the activities, of Vertical Impact Student Ministries of Armstrong Chapel United Methodist Church. • Further, We (I), hereby consent to and/or authorize another adult (Youth Pastor or person designated by Youth Pastor) in whose care the participant has been entrusted, to consent to any transportation to a licensed medical doctor or hospital, and to any treatment that such medical professionals may deem necessary, including but not limited to emergency surgery, x-ray procedure, and/or anesthesia. We (I) agree to assume responsibility for any and all medical bills. • Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we (I) hereby agree to assume all transportation costs related to such return. • Further, we (I), hereby give permission for images of my child, captured during regular and special Vertical Impact Student Ministries activities through video, photo, and digital camera, to be used solely for the purposes of Vertical Impact Student Ministries promotional material and publications, and waive any rights of compensation or ownership thereto. • By signing this form, I understand it is effective for two (2) years from date signed or until the minor has reached 18 years of age.

LIABILITY RELEASE: In consideration of my child's acceptance for participation in the activities of Vertical Impact Student Ministries of Armstrong Chapel United Methodist Church, we (I), being 18 years of age or older, for ourselves (myself) and for and on behalf of our (my) child participant, do hereby release, discharge and agree to hold harmless Vertical Impact Student Ministries, Armstrong Chapel United Methodist Church, the directors thereof and any other authorized adult chaperone from any and all liability, claims or demands for personal injury, sickness or death as well as property damage and expenses of any nature whatsoever, which may be incurred by the undersigned and/or our/my child participant while participating in that group's activities. If participant is under 18 years of age both parents must sign unless separated or divorced in which case the custodial parent must sign. Witness ____________________

_______________________________________

Witness ____________________

Father Signature

Print Name

Date: ________________________ Witness ____________________

_________________________________________

Witness ____________________

Mother Signature

Print Name

Date: ________________________ Witness ____________________

_________________________________________

Witness ____________________

Legal Guardian Signature

Print Name

Date: ________________________ Reviewed and reconfirmed, with any necessary revisions, on __________________, 20____. __________________________________ (parent signature) 1

20 November 2009

Armstrong Chapel United Methodist Church Parental Consent and Liability Release Form TRIP PARTICIPANT ONLY: I understand the rules of conduct for participants and will abide by them, as well as the directions of the leadership of the trip. Participant: ___________________________________________ Date: __________________

HEALTH INSURANCE: [Please circle]

Yes

No

(If Yes, please attach copy of insurance card)

Insurance Company Name, Claims Mailing Address & Phone Number Policy and Group Number Subscriber's Name

SSN

Physician

Physician's Phone Number

HEALTH INFORMATION: Medication Allergies Food or Environmental Allergies Check all items that apply, past or present, to your health history. Yes No ADD or ADHD Diabetes/Hypoglycemia Asthma Heart disease Cancer/blood disorder High blood pressure Convulsion/seizures Kidney disease Other

Yes

No

Explain any "yes" answers:

Please list all medications being taken:

List any physical or behavioral conditions that may affect or limit full participation in swimming, hiking, biking, running or playing strenuous physical games.

IMMUNIZATIONS: (Give date of last inoculation) Tetanus __________

Rubella __________

Diptheria __________

Polio __________

Pertussis __________

Hepatitis A __________

Measles __________

Hepatitis B __________

Mumps __________ 2

20 November 2009