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.
May 21, 2019