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MHCC Kids Release Form for the 2018-2019 year

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 2018 through August 2019.

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 2018 through August 2019 by a director or properly appointed adult sponsor of the student 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 2018 through August 2019.

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.

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 2018 through August 2019, 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.

October 19, 2018

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

Emergency Contact's 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.
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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