Covenant Youth Tobogganing 2023
Information received is confidential and is gathered for the purposes of serving your child while in the care of Covenant Christian Community Church. Any medical information collected here serves to authorize Covenant Christian Community Church, and its staff and volunteers, to obtain medical assistance in emergencies.
Sign in to Google to save your progress. Learn more
Student Name *
Health Card Number *
Allergies *
Does your child have any life threatening allergies? *
If yes, please explain: *
Parent/Guardian Name: *
Parent/Guardian Contact Number: *
In case of emergency, contact: *
Emergency Contact Relationship: *
Emergency Contact Phone Number: *
The safety of your child is our primary concern. Precautions are taken for the safety and health of your child. In the event that your child requires special medication, x-rays or treatment, the parents/guardians will be notified immediately. In the event that I/we cannot be reached in the case of an emergency, I/we, the parents or guardians named above, authorize Brent Jefkins or one of the Covenant Christian Community Church Ministry Staff to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment treatment or procedures for the participant named above. I/we named above, undertake and agree to indemnify and hold blameless the Pastor, the Ministry Staff, Covenant Christian Community Church its Pastors and Church Board from and against any loss, damage or injury suffered by the supervising individuals representing the church. This content and authorization is effective only when participating in the events of Covenant Christian Community Church. Please sign your name and date below confirming your agreement to the above information. *
Signed Name of Agreement *
Today's Date *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Covenant Christian Community Church. Report Abuse
Google Forms