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Pleasant Hill Christian Church Release Form

Pleasant Hill Christian Church is striving to maintain a high level of security for your child(ren) regarding promotional materials and website development.

The following is a request for your permission to use your child’s photo and/or first name. Please complete the appropriate blanks, sign and return to the church.

  • I, the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in the activities of Pleasant Hill Christian Church. Valid from May 2024 until May 2025.
  • The individual identified on this form understands that all participants are expected to abide by the rules of the adult sponsors in charge of this activity. If necessary, a participant may be required to leave due to misconduct or disobedience. I will assume full responsibility for returning the participant home.
  • Further, I do authorize the minister or sponsor of this activity, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment.
  • I release Pleasant Hill, its staff and sponsors from liability in the event of an accident.
  • I have read and agree to the information given in this entire form.
  • My consent and signature is given below.

 

Date: May 17, 2024



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
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*
Check to receive information, news, and discounts by e-mail.
Emergency Contact In Addition To Parents

Emergency Contact's Name: *

Emergency Contact's Phone Number: *

Parent's Name: *

Parent's Phone Number: *
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 Information
NAME RELEASE:*
Yes, I give permission for my child's first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.
No, I do not give permission for my child's first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.
PHOTO RELEASE:*
Yes, I give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.
No, I do not give permission for my child's photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.
WORLD WIDE WEB:*
Yes, I give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.
No, I do not give permission for my child's photo or other illustrating materials to be featured on the World Wide Web.

Health Insurance Information


Health Insurance Company

Policy Number

Known Allergies and Reactions

Medications Currently Taking
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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