FCC Youth Permission Form 2021-2022

*

Student's First & Last Name *

Student's Gender *

Male

Female

Student's Birthday *

MM

/

DD

/

YYYY

Student's Mobile Number (if applicable)

Student's Address *

School Attending *

Grade *

Mother's First & Last Name

Mother's Phone Number

Father's First & Last Name

Father's Phone Number

Guardian's First & Last Name

Guardian's Phone Number

Consent to Medical Treatment

By checking this box, I, the parent or guardian of the above student, a minor, do hereby authorize adult workers with the youth of Friendship Community Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me and do further agree to hold blameless any physician, hospital or other medical center for rendering such services. I also release and hold harmless Friendship Community Church, its staff, and its volunteers from liability resulting from any accident.

FCC Activities Consent

By checking this box, I, the parent or guardian of the above student, a minor, am giving permission for my student to participate in Friendship Community Ministry activities, both weekly and at special events, on site and off site and for my student to be transported by Friendship Community Church staff and volunteers to and from activities.

Consent to Medical Treatment

By checking this box, I, the parent or guardian of the above student, a minor, do hereby authorize adult workers with the youth of Friendship Community Church to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me and do further agree to hold blameless any physician, hospital or other medical center for rendering such services. I also release and hold harmless Friendship Community Church, its staff, and its volunteers from liability resulting from any accident.

Media Consent

By checking this box, I give permission for images and videos of my child to be placed on the Friendship Community Church website or other media outlets.

Insurance Company/Group Name

Policy Number

Please list student's allergies *

Please list student's regular medications. Please explain *

Does your student wear contacts/glasses? *

Yes

No

Is there any additional information about your student that the ministry team out to know? Please share here *

Signature of Parent or Guardian *

By typing my name below, I hereby certify that I am a legal guardian of named student and that all information above is accurate.