Children's Ministry Medical Release Form
For VBS 2023
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Parent's Name *
Phone Number *
Email *
Street Address
Child #1's Name (First and Last) *
Child #1's Date of Birth *
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Child #2's Name (First and Last)
Child #2's Date of Birth
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Child #3's Name (First and Last)
Child #3's Date of Birth
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Check the box to digitally sign this form and type your name below. I am the parent or legal guardian of the above named child and I am informed of the activities offered by First Presbyterian Church of Granada Hills. As the parent or legal guardian of my child, I hereby consent for my child to attend and participate in all activities provided by this church.
Check the box to digitally sign this PARENT/GUARDIAN CONSENT TO MEDICAL, DENTAL, or HOSPITAL CARE. I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further agree to pay all charges for the dental, medical, or hospital care or treatment. As parent or legal guardian of my child, I am responsible for the health care decisions of my child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered to my child is legally sufficient and that no consent from any other person is required by law.
IT IS MY INTENTION BY THIS AGREEMENT TO EXEMPT AND RELIEVE First Presbyterian Church of Granada Hills AND ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH OF MY CHILD(REN) CAUSED BY ANY ACT OF NEGLIGENCE Of First Presbyterian Church of Granada Hills AND ITS OFFICERS, AGENTS, SERVANTS OR EMPLOYEES. For and in consideration of permitting my child(ren) to observe or use any facility or equipment of First Presbyterian Church of Granada Hills, or engage in and/or received instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: First Presbyterian Church of Granada Hills, the undersigned parent and/or guardian of the above named child(ren) hereby voluntarily and absolutely releases, discharges, waives and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage or wrongful death occurring to the above named child(ren) as a result of the above named child(ren) observing or using facilities or equipment of First Presbyterian Church of Granada Hills, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian of the above named child(ren) for him/herself, his/her heirs, executors, administrators or assigns agrees that in the event any claim for personal injury, property damage or wrongful death shall be prosecuted against First Presbyterian Church of Granada Hills or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless First Presbyterian Church of Granada Hills and its officers, agents, servants or employees from any and all claims or causes of action by the above-named child(ren) or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of the above-named child(ren) present any claim against First Presbyterian Church of Granada Hills and said persons for personal injuries, property damage, wrongful death or otherwise cause by any act of negligence by First Presbyterian Church of Granada Hills and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
I, the undersigned, am the parent or legal guardian of the above-named child(ren). My child is attending and participating in the above-named activity(ies) at I, the undersigned, am the parent or legal guardian of the above-named child(ren). My child is attending and participating in the above-named activity(ies) at First Presbyterian Church (hereinafter “church”). I hereby authorize the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this (church) into whose care my child has been entrusted, to consent to medical care or dental care, or both for my child. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further authorize the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants or employees that are 18 years of age or older, who supervise the activities at this (church) to receive physical custody of my child, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants or employees that are 18 years of age or older who supervise the activities at this (church). It is understood that this authorization is given in advance of any special diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist and surgeon may deem advisable. I hereby authorize the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants, or employees that are 18 years of age or older, who supervise the activities at this (church) into whose care my child has been entrusted, to consent to medical care or dental care, or both for my child. The authority granted by this authorization includes the authority to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician and surgeon licensed under the Medical Practice Act for my child. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist licensed under the Dental Practice Act for my child. I further authorize the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants or employees that are 18 years of age or older, who supervise the activities at this (church) to receive physical custody of my child, upon completion of any treatment, and I specifically instruct any treating health facility to surrender physical custody of my child to the (supervisor/manager/pastor/camp director) and his/her officers, agents, servants or employees that are 18 years of age or older who supervise the activities at this (church). It is understood that this authorization is given in advance of any special diagnosis, treatment or hospital care being required but is given to provide authority and power on the part of the supervisor or his/her authorized designee, in the exercise of his/her best judgment, upon advice of such physician, dentist and surgeon may deem advisable.
Signature of Parent *
Date
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Additional Information (MEDICAL/HEALTH INSURANCE COMPANY INSURANCE POLICY # (IF APPLICABLE)
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