Fairview Youth Medical Form

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This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the church, its staff, and volunteer leaders or chaperones of any liability against personal loss, injury or accident related to participation in the event or transportation to or from the event of the child named in the form.

Student's Name *

Student's Birthdate
*

YYYY

Parent or Guardian's Name
*

Parent or Guardian's Phone Number
*

Health Insurance Company
*

Insurance Policy Number
*

Insurance Policy Holder's Name
*

Policy Holder's Phone Number
*

Allergies
*

Option 1

Current Medications
*

Other Medical Conditions/Restrictions
*

Disciplinary & Illness Agreement: I/we agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the Youth Leader for other behavioral or disciplinary reasons.
*

Yes

Bag Search Agreement: I/we also agree to allow the church staff and volunteer leaders or chaperones to search my/our child's personal belongings if deemed necessary.
*

Yes

COVID-19 Liability Agreement: I am fully and personally responsible for my child's safety and actions while and during may participation and I recognize that my child may be in any case be at risk of contracting COVID-19. With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using. I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
*

Yes

Media Release Agreement: I understand that grant or deny permission to Fairview Church to use the name, likeness, and image of my child as marked by my selection below. Such use includes the display, distribution, publication, transmission, or otherwise use of photographs, images, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on the Fairview Church website.
*

I grant permission to use my child's image in print, video, and digital media. I agree that these images may be used by Fairview Church for a variety of legally permissible purposes; ad that these images may be used without further notifying me.

I deny permission to use my child's name, likeness, or image.

Refund Policy: I understand that there will be no refund for this event. The only exception would be in the case that Fairview Church cancels the event.
*

Yes

Age Attestation: I certify that I am of legal age and competent to contract in my own name. I have read this release before signing below and I fully understand the contents, terms, and the effect of this release.
*

Yes

Attestation of Parent or Guardian: I am the parent or legal guardian of the named minor or minors in this agreement. I have read this release before signing below, and I fully understand the contents, terms, and the effect of this release.
*

Yes

Option 1

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