Parent Consent Form and Permission Waiver
Any parent/legal guardian needs to complete the entire form for all children under the age of 18 years of age, who will be attending any activities (i.e. summer camp, retreats, conferences, mission trips, special trips, etc.) with First Christian Church of Marshall, IL.   

Please complete one form per child.  All forms are good for one year.
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Last Name of Child *
First Name of Child *
Mailing Address *
City, State, and Zip Code *
Home Phone Number 
Cell Phone Number
Work Phone Number
Email Address
Date of Birth of Child *
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DD
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Gender
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Age
Current Grade 
Emergency Contact  Name #1 *
Emergency Contact #1 Relationship to Child
Emergency Contact #1 - Phone
Emergency Contact #2
Contact #2 Name *
Contact #2 Relationship to Child
Contact #2  Phone number
Medical Information
Insurance Company Name *
Policy / Group #
Policy Holder's Name
Insurance Phone Number
Primary Care Provider
Physician's Name
Allergies - Please be specific
Medications 
Special Needs - please be specific
In Case of Emergency

I hereby give authorization to an adult leader of the events within this year, as agent for me, to consent to an X-Ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) license to practice under the laws of the state where the serves are rendered, either at a doctor's office or in any hospital. I expect to be contacted as soon as possible.  

This is also to certify, to the best of my knowledge, that the above named has no physical handicaps or illnesses (except as noted on this form).

I hereby release First Christian Church of Marshall, its staff, and sponsor from responsibility and liability for any injury that the above named may sustain during church sponsored activities.  
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Transportation Release

I hereby give permission for my child to ride in any designated vehicle by First Christian Church of Marshall, IL. 

I release and hold harmless from liability First Christian Church of Marshall, the staff and/or any volunteers for any injury my child receives during transportation to and from any activities. 
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Video / Image Release

I hereby give my permission for the image of my child to be taken by either video or still camera for the event and such images are to be used for the purposes of First Christian Church of Marshall. 
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Signature of Parent / Legal Guardian
Date Signed
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Submit
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