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2021 LCPC CHILDREN’S & YOUTH MINISTRY PERMISSION SLIP

LA CAÑADA PRESBYTERIAN CHURCH
PERMISSION SLIP, WAIVER, MEDICAL AUTHORIZATION AND RELEASE

FUNCTIONS AND ACTIVITIES
It is my understanding that participating in the programs and recreational and other activities of La Cañada Presbyterian Church (“the Church”) is a privilege. Prior to my child’s participation in such activities, I acknowledge that certain risks are associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

The undersigned hereby give our consent to and authorize the minor child named above to participate in all events conducted by the Church. I further authorize my minor child to travel with representatives of the Church in private or other vehicles to any such events so conducted.

PUBLICITY
On occasion, the Church takes photographs or makes an audio or videotape recording of children and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in La Cañada Presbyterian Church publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our Church may allow them to photograph or record our events for news reporting on special interest features. By signing this form, you consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, audio recordings, and the Church’s web page.

RELEASE OF LIABILITY
By signing this form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I, the undersigned, for my child, my child’s personal representatives, assigns, heirs, distributees, guardians, and next of kin (“the Releasors”), hereby irrevocably and unconditionally release, waive, discharge, and covenant not to sue the Church and its ministers, leaders, employees, volunteers, and agents, for and from all claims of any nature now or hereafter existing whether known or unknown, including but not limited to, all liability to the Releasors, on account of injury to my child or death to my child or injury to the property of the child, whether caused by the negligence of the Church, its ministers, leaders, employees, volunteers, and agents or otherwise, during the course of my child’s participation in the activities, arising out of or in connection with activities related to the Church, or any travel connected therewith.

FIRST AID AND EMERGENCY MEDICAL TREATMENT
I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of the Church to seek and secure any needed medical attention or treatment for the child named including hospitalization, if in the opinion of the agent such a need arises. Further, I authorize the agent of the Church to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is rendered under the general or special supervision of, any physician, surgeon, or dentist licensed under the laws of the State or County in which the medical care is being sought and on medical staff of any hospital. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment including any treatment a physician, surgeon, or dentist may deem necessary.

It is understood that this authorization is given in advance of any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care being required but is given to provide authority and power on the part of the agent to give specific consent to any and all such examination, anesthetic, diagnosis, treatment, or hospital care which the aforementioned physician, surgeon and/or dentist, in the exercise of his/her best judgment, may deem advisable. I hereby authorize any hospital which has provided treatment to my child to surrender physical custody of the child to the agent upon the completion of treatment.

Date Signed: June 24, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 20 years of age or older
First Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
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 Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent / Legal Guardian Contact Information

Home Phone *

Name of Father *

Cell Phone *

Father's Email

Work Phone

Name of Mother *

Cell Phone *

Mother's Email

Work Phone
I represent that I am the parent/guardian of minor(s), who is under 18 years of age. I have read the above form and am fully aware of the contents thereof. I give permission for the child named above to participate in the activities of La Cañada Presbyterian Church, including any special events/activities. In consideration for allowing the participation of the child in the activities of LCPC, I hereby consent to the above terms on behalf of the child and agree that this form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns. In the event that any of the above information should change, I (we) understand that it remains my (our) responsibility to communicate the updated information to the Children's Ministry Director(s) in a timely manner. This document is valid for one year from the date of signature.
Parent or Guardian Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
I certify that I am 20 years of age or older
Parent or Guardian Information

Age *

Grade *

School *

Food allergies/dietary restrictions? (PLEASE LEAVE BLANK IF NONE)

MEDICAL HISTORY


Special medical needs/concerns: (PLEASE LEAVE BLANK IF NONE)

Date of Last Tetanus Shot *

Other Information


Other information church leaders should know about the child: (PLEASE LEAVE BLANK IF NONE)
Parent or Guardian 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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