Loading...

FCC Permission Slip and Activity Participation Agreement (Minors)

To be completed by a parent or legal guardian for all minors participating in Children's, Youth, or other Church Activities, whether on the FCC campus or elsewhere. This Permission Slip is valid for activities from June 1, 2024 through May 31, 2025.

Participant Agreement

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by First Covenant Church (FCC), its employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless FCC for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of FCC, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternate dispute resolution process. If the participant (or parent/guardian) and FCC cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rule of the American Arbitration Association.

I Agree

November 21, 2024

Code of Conduct

We expect all participants to comply with this Code of Conduct while participating in activities.

  • No students can drive without parental permission and staff approval.
  • No possession or use of alcohol, drugs, or tobacco.
  • No weapons, fireworks, lighters, or explosives.
  • No offensive or immodest clothing.
  • No sexual activity, sexual harassment, or sexually explicit media.
  • No hateful speech, racism, fighting, slander or bullying.
  • No male in female sleeping quarters and no female in male sleeping quarters.
  • Respect one another, staff, adult leaders, and all personal/public property.
  • Respect, Participate and Comply with group event schedules and regulations.

Anyone who fails to comply with these expectations may be sent home at their expense. 

I have read the rules of conduct, the above evaluation of my health, and permission to participate in FCC activities. I agree to abide by the stated personal limitations and code of conduct.

I Agree

November 21, 2024

Permission & Release

Activities may include, but are not limited to cookouts, boating, water skiing, swimming, basketball, roller skating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides. Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the church youth pastor prior to that event.

I give consent to the use of any videotapes, photographs, slides, audiotapes, or any other video or audio reproduction in which my student appears. I understand that these materials are being used for promotion of First Covenant Church youth ministry. Such promotional activities extend to recruitment, advocacy, fundraising, etc. Pictures may appear on the Church website. I release the staff and volunteers from any liability connected with the use of my picture or voice recording as part of any of the above or similar activities.

To the best of my knowledge, the information on this form is accurate and complete and I understand that I am signing for the minor listed on this form and the signature is for both medical and liability release.

I Agree

November 21, 2024

First Parent or Legal Guardian's Name

First Name*

Last Name*

Phone*
First Parent or Legal Guardian's Age Acknowledgment*
First Parent or Legal Guardian's Date of Birth*
I certify that I am 18 years of age or older
First Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
First Parent or Legal Guardian's Signature*
Second Parent or Legal Guardian's Name

First Name*

Last Name*
Second Parent or Legal Guardian's Date of Birth*
Second Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Third Parent or Legal Guardian's Name

First Name*

Last Name*
Third Parent or Legal Guardian's Date of Birth*
Third Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Fourth Parent or Legal Guardian's Name

First Name*

Last Name*
Fourth Parent or Legal Guardian's Date of Birth*
Fourth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Fifth Parent or Legal Guardian's Name

First Name*

Last Name*
Fifth Parent or Legal Guardian's Date of Birth*
Fifth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Sixth Parent or Legal Guardian's Name

First Name*

Last Name*
Sixth Parent or Legal Guardian's Date of Birth*
Sixth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Seventh Parent or Legal Guardian's Name

First Name*

Last Name*
Seventh Parent or Legal Guardian's Date of Birth*
Seventh Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Eighth Parent or Legal Guardian's Name

First Name*

Last Name*
Eighth Parent or Legal Guardian's Date of Birth*
Eighth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Ninth Parent or Legal Guardian's Name

First Name*

Last Name*
Ninth Parent or Legal Guardian's Date of Birth*
Ninth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Tenth Parent or Legal Guardian's Name

First Name*

Last Name*
Tenth Parent or Legal Guardian's Date of Birth*
Tenth Parent or Legal Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
Parent or Guardian's Email Address

Email*

Confirm Email*
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*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Grade*

Emergency Contact Name *

Emergency Contact Phone *

Allergies/Medical Conditions that FCC Staff/Volunteers should be aware of
Is FCC authorized to approve medical treatment?*
No
Yes
Is the participant covered by personal/family medical insurance?*
No
Yes

Medical Insurer Name *

Medical Insurance Policy or Group Number *

Doctor's Name *

Doctor's Address *

Doctor's Phone *

Dentist's Name *

Dentist's Phone *

Dentist's Address *
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!