Universal Permission Form - Redeemer Students

Your name *

Email address *

Child's Nickname, if any?

Address *

Child's Secondary Address, if any?

School (Name and Address) *

Child's Email Address, if any?

Child's Phone Number (Home and/or Cell)

Parent/Guardian Name *

Parent/Guardian Phone Number *

Secondary Contact Name *

Secondary Contact Phone Number *

Additional Contact Name

Additional Contact Phone Number

Authorized Individuals

Separate from the emergency contact list, the following are individuals able to pick up your child at the conclusion of an activity.

Activity Release Information *

Please indicate if you do or do not permit your child to leave an activity on their own. If not, please list below the individuals authorized to pick up your child at the conclusion of an activity.

YES. My child (who is in the sixth grade or above) is allowed to leave an activity on his/her own at the conclusion of the activity.

NO. My child is not allowed to leave an activity on his/her own, even if he/she is in the sixth grade or above.

Child Medical Information

Primary Care Physician (PCP) Name *

PCP Name of Practice *

Date of last Tetanus shot *

Medical Insurance Company *

Insurance Company Phone Number *

Policy Holder's Name *

Medications *

List all medications your youth/child will take during any activity including childcare, children’s church, Redeemer Students, youth ministry trips, retreats, or other events. This includes any prescription, non-prescription medications, herbal supplements, and vitamins.

Please list the medication name, dosage, treatment reason, and dispensing instructions

Do you require the adult youth leader to carry and administer the medications listed above?

Check one of the following:

No. Medications must be properly secured and administered by the youth/child at all times.

Medications must not be shared with any other youth/child. Any abuse of this policy may result in disciplinary action up to and including being sent home at the parent/guardian’s expense. Sharing prescription drugs with others is prescription fraud and may be subject to severe penalties.

Yes. Give all medications to the adult youth leader in their original containers with complete dispensing instructions before the start of the event.

Over-the-Counter Medication Permission

Do you give permission for your youth/child to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while participating in an event? Check one of the following:

No. Contact me or get medical help if my child has any minor medical concerns.

Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.

Medical Conditions

Please answer in detail if applicable or write N/A.

List any medical conditions your youth/child has (asthma, diabetes, epilepsy, etc.) *

List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction *

Please explain any other pertinent information about your youth/child (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know *

Parental Consent

The undersigned does hereby give permission for my child identified above (the “Minor”) to attend and participate in any Redeemer Community Church children/student ministry activities, events, retreats, and childcare (collectively referred to as the “RCC Ministries”).

MEDICAL TREATMENT PERMISSION *

I authorize an adult, in whose care the Minor has/have been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the Minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the Minor pursuant to this authorization.

TRANSPORTATION PERMISSION *

The undersigned does also hereby give permission for the Minor to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in RCC Ministries. The Minor and the undersigned understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

LIABILITY RELEASE *

I acknowledge that participation in RCC Ministries involves risk to the Minor and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration of the opportunity for the Minor to participate in RCC Ministries, the undersigned acknowledges and accepts the risks of injury associated with participation in and transportation to and from the RCC Ministries. The undersigned accepts personal financial responsibility for any injury or other loss sustained during the RCC Ministries or during transportation to and from the RCC Ministries, as well as for any medical treatment rendered to the Minor that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “Activity Sponsor”). Further, the undersigned releases and promises to indemnify, defend, and hold harmless Redeemer Community Church and the Activity Sponsor for any injury arising directly or indirectly out of the RCC Ministries or transportation to and from the RCC Ministries, whether such injury arises out of the negligence of the activity sponsor, the Minor, or otherwise.

If a dispute over this agreement or any claim for damages arises, the undersigned agrees to resolve the matter through Alternative Dispute Resolution services provided by Christian Legal Society or other mutually agreeable Christian Alternative Dispute Resolution service.

PHOTO RELEASE *

Redeemer Community Church regularly photographs, videotapes, or records by other visual and/or sound recording devices during its RCC Ministries. If you do not want your Minor’s photograph or image to be used by Redeemer Community Church in video presentations, publications, promotions, on our website, or any other lawful manner, please notify the church office in writing and every effort will be made to assure that the Minor’s photograph or image will not be used.

Absent written notification to the contrary, the undersigned agrees that Redeemer Community Church may photograph and record the Minor’s likeness and activities (the “Images”) during RCC Ministries. I grant the following rights to Redeemer Community Church: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the recording(s). Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge Redeemer Community Church from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other harmful acts.

EARLY RETURN HOME POLICY *

Should it be necessary for the Minor(s) to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

AGREEMENT | Guardian Must Sign *

By applying my electronic signature to this agreement, I agree that my electronic signature is the legally binding equivalent of my handwritten signature on paper. I will not, at any future time, claim that my electronic signature is not legally binding or enforceable. By electronically signing and submitting this agreement, I 1) acknowledge that I have read and fully understand the terms of the agreement; 2) voluntarily agree to be bound by this agreement; and 3) certify that I am 18 years of age or older. My signature applies to all pages of this contract.

A parent or legal guardian must sign this agreement on behalf of any minor participant under the age of 18. By electronically signing this agreement, I represent that I have the authority to sign and enter into this agreement on behalf of the minor listed above.

PRINT NAME BELOW to sign release