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Project Timothy Midwest North

Liability Waiver

Vineyard Student Ministries Parent Permission Form

I, the undersigned parent/guardian of the named child, understand that my child is responsible for the knowing the rules and regulations made by the Duluth Vineyard Church and the sponsors of these activities. I understand that the breaking of these rules could result in the student being sent home at the expense of the guardian/parent.

I hereby authorize the adult leader of this activity to transport the named child to the destination of this event, or to a medical doctor for examination and treatment of any accident or illness that may arise during the term of said activity. I understand that in the event of a medical emergency, every effort will be made to contact the parent/guardian listed. In the event I cannot be reached, I hereby authorize any physician, nurse, medical authority and/or hospital to administer proper treatment for my child. In consideration of this acceptance for said activity, the Vineyard Church (i.e.. staff, leaders, or volunteers) is hereby released and relieved from liability for accident and injury to said child arising from any and all activities of this event.

I have listed all known allergies, immunizations and health problems and any other information pertinent to named child’s health, including all medications named child takes on the Duluth Vineyards Medical Release Form*. Permission is hereby given for my named child’s leader to administer prescription medication as directed on the original prescription medication container. Permission is also hereby given for the staff of the Vineyard Church and/or my named child’s leader to administer generic over-the counter medications (i.e. ibuprofen, aspirin, tums etc...) as directed by the labels provided by the manufacturer for my child:

Dated: September 17, 2021

*We ask parents/guardians to flll out a Medical Release Form for 2017-2018 to ensure exact medical/insurance information. Forms are available at duluthvineyard.org or email jpeterson@duluthvineyard.org to receive one via email.

Please select who will be participating...
Minor
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

Grade:

School:
First Participant's Signature*
Participant's 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*
Insurance Information

Students Health Insurance Carrier:

Students Policy #:
Medical Information

Date of Last Tetanus Shot: *

Current Medications:

Allergies:

Any Special Medical Instructions or Things to Be Aware of:

In the event that we can't be reached, an emergency call may be made to the following person:


Name:

Phone #:

I hereby authorize the adult leader of this activity to take the named child to a medical doctor for examination and treatment of any accident or illness that may arise during the term of said activity. I understand that in the event of a medical emergency, every effort will be made to contact the parent/guardian listed. In the event I cannot be reached, I hereby authorize any physician, nurse, medical authority and/or hospital to administer proper treatment for my child. In consideration of this acceptance for said activity, the Vineyard Church (i.e.. staff, leaders, or volunteers) is hereby released and relieved from liability for accident and injury to said child arising from any and all activities of this event.

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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Grade:

School:
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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