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This form must be completed and signed by a Parent/Legal Guardian for any student who wants to participate in any CCWC Children's Ministry Activities. 

This form must be completed and signed by a Parent/Legal Guardian for any student who wants to participate
in any CCWC Children's Ministry Activities. This form will be kept on file and will be valid for a period of one (1) calendar year from the date signed. It is the responsibility of the undersigned Parent/Guardian to inform the Children's Ministry Staff at CCWC of any changes to the student’s personal or medical information. 

The undersigned hereby further authorizes any of the staff, employees, volunteers, directors and agents of
CCWC to provide for, approve and authorize any health care at any hospital, emergency room, doctor’s
office or other institution; employ any physicians, dentists, nurses, or other person whose services may be
needed for such health care; review and if necessary disclose the contents of any medical records; execute
any consent form required by medical, dental or other health authorities incident to the provision of
medical, surgical, or dental care to the Student. Health care shall include but not be limited to the
administration of anesthesia, X-Ray examination, performance of operations, diagnostic and other
procedures. All medical bills accumulated will be the sole responsibility of the parent or legal guardian.
CCWC or its staff will not be held liable for any incurred medial expenses. Parent or Legal guardian
agrees to be the responsible party for making sure medical coverage is placed on student.
In any occurrence of a medical injury/emergency, the CCWC representative will use every reasonable
effort to contact the parent(s)/guardian(s) before administering or authorizing any treatment. If contact is
unable to be made after the attempts have been exhausted, CCWC leadership/representatives will be
automatically given authorization by parents/legal guardians to give immediate care as needed and
suggested by medical doctors. In a life-threatening situation, all focus and immediate attempts will be
made to save the life as first priority. In this case, parents will be notified immediately during care.
Notwithstanding other provisions in the Consent Form, CCWC shall not have the authority to withhold or
withdraw life-sustaining procedures for the Student.

The undersigned further acknowledges that any CCWC activity may include Student being transported in a
personal vehicle, a van or a bus. CCWC and its drivers will not be held liable for any accidents or injuries
obtained while transporting to and from destination of approved youth church events, camps or activities.
The undersigned assumes all risk of injury or harm to the Student associated with participation in the
Student Ministry activities and agrees to release, indemnify, defend and forever discharge CCWC church,
OneEighty Youth Ministry and its staff, employees, volunteers, directors and agents of and from all
liability, claims, demands, damages, costs, expenses, actions and causes of action (collectively, the
“Claims”) in respect of death, injury, loss or damage to the Student or by the Student, howsoever caused,
arising or to arise by reason of or during the Student’s participation in the activity.
The undersigned assumes all transportation costs and responsibility should it be necessary for the Student
to return home due to medical reasons, disciplinary action or otherwise.
This Consent Form may be revoked by parent(s)/guardian(s) at any time before the expiration date with
written notice to CCWC’s Children's Ministry PRIOR to any trip taken and personally handed in
to lead Pastor of Ministry.

 

September 22, 2019

 

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
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*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Important Info

Please specify any important medical information we should be aware of. 

What school does this student/these students attend? (If applicable)

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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