Born Church Consent Form (2021-2022)

Participant First and Last Name *

Date of Birth * +

Participant Grade *

Participant Email

Participant Phone

Street Address *

May a staff member of Born contact your child. (6th grade and older only) *

Yes

Is your child allowed to walk home? *

Yes

Participant Allergy and/or Health Conditions *

Participant Medications *

Parent/Guardian First and Last Name *

Parent/Guardian Email *

Parent/Guardian Phone Number *

Emergency Contact First and Last Name *

Relation to Participant *

Emergency Contact Phone *

I, the undersigned, confirm that: *

1. In case of emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give permission to the physician selected by the supervising adult to administer prescribed treatment to my child.

2. I understand that photographs or video taken of my child during any event can be used in Born Church publicity including but not limited to live streaming, website and printed materials.

3. I understand that my child may transported by Church bus and/or volunteer driver vehicle if needed. When volunteer drivers are used, every precaution will be taken to ensure that they are properly screened, licensed and insured. Every effort will be made to inform you when your child needs to be transported.

4. This is a permission form for any participant of Born Church. It shall apply to any and all events within a day’s drive of Marion, IN that may be scheduled during the listed dates on this form. Events beyond this distance will require a separate permission & health form.

5. Your consent may be canceled at any time upon written or verbal contact with the area Program Director.

By signing below I am confirming that I am a parent or have the legal authority to give permission for the above named to participate in Born Church activities.

Parent or Legal Guardian Signature *

clear

Todays Date * +

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