Permission and Medical Release Form for Mosaic Community Church Youth Groups 2024

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Please complete this form for each child in your care. This form is valid from the date completed to the end of December 2024.

What is your child's name?

Minor's Birthdate

YYYY

Minor's Grade

Does the child have any food or environment allergies? Please list.

Medication Currently Being Used

Parent or Guardian's Name

Parent or Guardian's Phone Number

Please list emergency contact information if a parent/guardian cannot be reached. Provide name, phone number and what type of relationship they have to the child.

I give permission for my son/daughter, named above, to attend Sunday Evening Dinner and Youth Group at Mosaic Community Church from the date signed until the end of December 2024.

Yes

Clear selection

I give permission for my son/daughter, named above, to ride church transportation on Sunday nights, as well as to and from any special events.

Option 1

Clear selection

Photos of my son/daughter may be used for church publications and websites.

Yes

Clear selection

Permission Form

Mosaic Community Church counts it a privilege to have your son/daughter participate in our activities.
Because of that, we go to great lengths to provide safe and fun activities in a safe environment, and recruit safe drivers for activities that require transportation. That being said, we understand that accidents do happen, and would remind you that your signature releases Mosaic Community Church and its agents from liability as
stated below:

I the undersigned, DO WITH THIS FORM RELEASE MOSAIC COMMUNITY CHURCH and its employees, volunteers, and anyone present FROM ALL LIABILITY for mishap or injury to my child while participating in the aforementioned ministry program. THIS RELEASE INCLUDES ANY AND ALL MISHAPS OR ACCIDENTS RELATED TO THE TRANSPORTING OF MY CHILD TO AND FROM ACTIVITIES. (Type name below to sign.) *

Signature Date

YYYY

The undersigned do hereby authorize a member of the Mosaic Community Church Staff or such substitute as he/she may designate, as agent for the undersigned to consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon licensed under the Provision of Medicine Practice Act or of any dentist licensed under the Dental Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp, or elsewhere.This authorization will remain effective while the above minor is en route to or from or involved or participating in any program or activity of the Mosaic Community Church, Jeannette, PA unless revoked in writing by the undersigned, and delivered to the aforesaid agent.

Signature Date

YYYY

Submit

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