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MHCC Kids Release Form | September 2022-August 2023 


Liability Release and Consent to Travel

I, being the parent/legal guardian of named minor, do hereby release Mendham Hills Community Church, its agents, assigns, employees, and volunteer assistants from any liability whatsoever arising out of injury, sickness, damage, or death, which may be sustained by myself or the above minor during any activity, trip, function, or the like-sponsored by or participated in by Mendham Hills Community Church from September 2022 through August 2023.

I also give my permission for the above named minor to attend and be transported to any activity, trip, function or the like sponsored by Mendham Hills Community Church from September 2022 through August 2023 by a director or properly appointed adult sponsor of the children's ministry of Mendham Hills Community Church.


Medical Release

I, being the parent/legal guardian of named minor, do hereby give my consent for the children's ministry directors or properly appointed adult sponsor of the children's ministry of Mendham Hills Community Church to secure the administration of medical treatment or medication for the above named individual and do further agree to the performance of such treatment, anesthetic, and/or operations, as in the opinion of the attending physician is deemed necessary for myself or the above named minor while at any activity, trip, function, or the like sponsored by Mendham Hills Community Church from September 2022 through August 2023.

I have informed Mendham Hills Community Church of all prescribed or over-the-counter medications that my minor is currently taking, all restrictions on medical treatment to be provided, of all allergies to medications and of special medical requirements by listing them on the reverse side of this form.


COVID-19 Release

COVID-19 is contagious and is believed to spread mainly from person-to-person contact. Mendham Hills Community Church cannot guarantee that your child will not become infected with COVID-19. Further, attending the MHCC in-person activities could increase your child's risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child and I may be exposed to or infected by COVID-19 by attending any MHCC event and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at MHCC may result from the actions, omissions, or negligence of myself and others, including, but not limited to, MHCC employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child may experience or incur in connection with my minor’s attendance at MHCC or participation in MHCC programming (“Claims”). On my behalf, and on behalf of my minor, I hereby release, covenant not to sue, discharge, and hold harmless Mendham Hills Community Church, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of MHCC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any MHCC program.


Disciplinary Agreement

I, being the parent/legal guardian of named minor, understand while the above named minor participates in any activity, trip, function or the like either sponsored by or participated in by Mendham Hills Community Church from September 2022 through August 2023, the above named minor, is responsible to abide by the rules set forth by the sponsored organization, its leaders and/or all supervisory personnel.

Any infraction of rules and/or conduct by the above named person(s), deemed to be serious by any director or properly appointed adult sponsor of the children's ministry of Mendham Hills Community Church, can result in corrective action, up to and including dismissal from the event. In the event that the above named minor is dismissed from the program, I the minor’s legal guardian agree to assume the entire cost of returning home, to forfeit any monies paid for the cost of the trip/event, and to assume responsibility for any monies owed for the cost of the trip/event. I fully understand and agree that there will be no refund of the cost of returning home.


I agree to all of the above statements and all information provided on the reverse of this form is complete, accurate and true to the best of my knowledge.

May 9, 2025


Please select MINOR for your Child
AdultMinor
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First Child Name

First Name*

Last Name*

Phone*
First Child Date of Birth*
First Child Signature*
Child Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medications

Are there any medications that the child is allergic to? *

Are there any medications or treatments that should not be given to the child because of adverse or dangerous reactions? (Please list reaction) *

Any medications being taken regularly by the child? (List all over the counter and Rx) *
Medical History

Any other allergies in addition to medications listed above? *

Are there any medical conditions or physical limitations or disabilities that the child may have that would limit his/her ability to participate in any activity? *

Anything else we should be aware of? *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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