Please copy and paste the following post into a Word document, fill it out, and fax it to 626-799-9968 or mail to our church address with your payment ($30 per child):
Vacation Bible School 2009
Oneonta Congregational Church
1515 Garfield Dr. South Pasadena CA 91030
PERMISSION SLIP, WAIVER, MEDICAL AUTHORIZATION AND RELEASE
Effective January 11, 2009
Name of Student__________________________________Age____Birth date________________
Address __________________________________________________________________________
City ___________________________________State__________ Zip_________________________
Grade last completed______________________Sex_________________T-shirt size______________
Name of Parent/Gaurdian__________________________________________________________
Mailing address if different than above___________________________________________________
Primary Phone______________________________Secondary phone________________________
E-mail address______________________________Allergies ________________________________
FUNCTIONS AND ACTIVITIES It is my understanding that participating in the programs, recreational and other activities of Oneonta Congregational Church Vacation Bible School is a privilege. Prior to my student’s participation in such activities, I acknowledge that certain risks are associated with the activities, including, by way of example, physical injury due to activity-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
The undersigned hereby give our consent to and authorize the minor child named above to participate in all VBS events conducted by the Church.
Initial here________
PUBLICITY On occasion, the Church takes photographs or makes an audio or videotape recording of students and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in Oneonta Congregational Church publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our Church may allow them to photograph or record our events for news reporting on special interest features.I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, audio recordings, and the Church’s web page.
Initial here_________
It is understood that this authorization is given in advance of any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care being required but is given to provide authority and power on the part of the agent to give specific consent to any and all such examination, anesthetic, diagnosis, treatment, or hospital care which the aforementioned physician, surgeon and/or dentist, in the exercise of his/her best judgment, may deem advisable. I hereby authorize any hospital, which has provided treatment to my student to surrender physical custody of the child to the agent upon the completion of treatment. Initial here_________
FIRST AID AND EMERGENCY MEDICAL TREATMENT I recognize that there may be occasions where the student named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of Oneonta Congregational Church to seek and secure any needed medical attention or treatment for the student named including hospitalization, if in the opinion of the agent such a need arises.
Further, I authorize the agent of the Church to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of, any physician, surgeon, or dentist licensed under the laws of the State or County in which the medical care is being sought and on medical staff of any hospital. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment including any treatment a physician, surgeon, or dentist may deem necessary. Initial here_________
RELEASE OF LIABILITY By signing this form, I expressly warrant that the student named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I, the undersigned, for my student, my student’s personal representatives, assigns, heirs, distributees, guardians, and next of kin (“the Releasors”), hereby irrevocably and unconditionally release, waive, discharge, and covenant not to sue the Church and its ministers, leaders, employees, volunteers, and agents, for and from all claims of any nature now or hereafter existing whether known or unknown, including but not limited to, all liability to the Releasors, on account of injury to my child or death to my child or injury to the property of the child, whether caused by the negligence of the Church, its ministers, leaders, employees, volunteers, and agents or otherwise, during the course of my student’s participation in the activities, arising out of or in connection with activities related to the Church, or any travel connected therewith. Initial here__________
MEDICAL HISTORY Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.): _________________________________________________________________________________
Health Insurance Company ___________________________________
Phone Number ___________________ Policy Number _____________________
Medical Doctor _____________________________________________________
Phone Number _____________________________________________________
Date of Last Tetanus Shot _____________________________________________
Emergency contact information:
Name ______________________Relation to child____________________Primary phone_________________secondary #___________________
Address_______________________________City_________________________Zip_________________
Name ______________________Relation to child_____________________Primary phone________________secondary#____________________
Address_______________________________City_________________________Zip_________________
Other information VBS leaders should know about the child:________________________________________________________________
PARENT(s) OR GUARDIAN(s) SIGNATURE I_______________________________ represent that I am the parent(s)/guardian(s) of _______________________________________ , who is under 18 years of age. I/We have read the above form and am fully aware of the contents thereof. I/We give permission for the student named above to participate in the activities of Oneonta Congregational Church, including any special events/activities. In consideration for allowing the participation of the student in the activities of the Church, I/We hereby consent to the above terms on behalf of the child and agree that this form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
Signature of Parent or Legal Guardian ____________________________________Date___________
Print Name of Parent or Legal Guardian ___________________________________
Signature of Parent or Legal Guardian ____________________________________Date__________
Print Name of Parent or Legal Guardian____________________________________
YOUNG PERSON’S AGREEMENT I agree to participate in the functions and activities of the Church, to cooperate with the leaders and other children, and to conduct myself according to Christian values. I promise to respect God, respect myself, respect other persons, and respect property. I understand that my continued participation in church activities depends on my support of this agreement.
Student’s Signature___________________________Print Student Name _________________________Date__________
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