Permission Waver

First Presbyterian Church Westminster, MD
Parental Permission, Emergency Medical Authorization and Release of Liability Form

***Required for every student participating in youth events***

* Indicates required field

Participant *

First

Last

D.O.B. *

Participant's Address *

Line 1

Line 2

City

State

Zip Code

Country

School: *

Grade Level: *

Parent / Guardian *

First

Last

Parent / Guardian Phone # *

Parent /Guardian Cell # *

**If you have a preferred method of primary contact, , ie: Phone, text, Email, Facebook, Instagram, Group me, Facebook Messenger etc., please let us know! We will make every effort to reach you in the most convenient way FOR YOU! *

Parent / Guardian Email *

Contact Preferences *

Home Cell May we text you on your cell #

Youth Communication Preferences:

Select One *

Check all that apply: *(If NOT a High School student, leave this section blank) *

Do we have permission to communicate directly with your HIGH SCHOOL STUDENT regarding youth events, including rsvp requests? I would like to be cc’d on all direct correspondence we make with your child

Youth Cell: *

Youth Email *

Photo Publication Permission:

I give consent for FPC to publish untagged photos of my child in the locations listed. *

Yes No

Throughout the year, at various events, photos are taken of our youth. These photos may be shared on the church bulletin boards, church publications, the FPC website, the church Facebook page (First Presbyterian Church of Westminster), The FPC Youth Shutterfly page, Group me, or the youth Instagram page (FPCyouth21157). Please let us know if we may publish photos of your child.

Information regarding youth activities will be regularly posted in the Grapevine, the Messenger, the FPC website, Shutterfly, Instagram, Group Me and mailed postcards.

Emergency Procedures:

In an emergency contact: *

First

Last

Phone Number *

Relationship to participant: *

Emergency contact 2: *

First

Last

Phone Number *

Relationship to participant *

Emergency Contact 3 *

First

Last

Phone Number *

Relationship to participant *

Does the minor have any special circumstances of which we should be aware? *

Medical Insurance Information:

Insurance Name: *

Name of Insured: *

Minor's Doctor: *

Policy # *

Group # *

Phone # *

** Copies of insurance cards will be required for any out of town trips.**

I give consent for:
  (1)the above-named minor to participate in First Presbyterian Church Youth Group activities from September 2019-August 2020. I understand that the minor may need to be transported in or around the Westminster and surrounding areas in order to participate in the Youth Group activities and I give my consent for a designated youth leader to transport the minor.

                (2)the administration of any emergency medical treatment for the above-named minor deemed necessary by a health care professional and the transfer of the minor to any medical facility reasonably accessible, provided that all reasonable attempts to contact me have been unsuccessful.

                In consideration for First Presbyterian Church arranging Youth Group activities, I hereby waive all claims against First Presbyterian Church, its officers and members and release them from any and all liability which they might have in connection with any injury, illness, or loss of property which may occur to the minor as a result of participation in the Youth Group activities.

                The minor has health and hospitalization insurance or medical assistance which will provide for his/her medical expenses in the event of injury. I understand that First Presbyterian Church is not responsible for providing medical care at its expense in the event of the minor’s injury or illness as a result of participating in Youth Group activities.

                This Parental Permission, Emergency Medical Authorization, and Release of Liability Form is effective from the date of execution through August 31, 2020, unless expressly revoked in writing.

Signature of Parent or Guardian *

Date: *

Questions regarding youth activities can always be addressed to [email protected] or [email protected]

Submit

(Fill out this online registration form or download
the file below, print, and return to the youth leader.)

permission_waiver_20172018.pdf
File Size:	620 kb
File Type:	pdf

Download File