All Activities Form, September 1, 2022-August 31, 2023

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Student Information - Parent Consent/ Medical Treatment Form
***By e-signing and accepting the form below, I am giving permission for my student to participate in Washington Alliance Youth Ministry activities, both weekly and at special events, on-site and off-site.

Email *

Student's First & Last Name *

Student's Gender
*

Male

Female

Address *

Birthdate *

YYYY

Student's Cell Number

Home Phone Number
*

School Attending
*

Grade Level
*

Parent/ Guardian Email
*

Mother's First & Last Name

Mother's Cell Number

Father's First & Last Name

Father's Cell Number

Guardian's First & Last Name

Guardian's Cell Number

Parent Consent for Photos

I hereby give permission for images and videos of my student that may be captured during their experiences to be used for the purpose of Washington Alliance training, promotional material, and publications and waive any rights of compensation or ownership thereto. (If your student is not permitted to have his/her photo taken for these purposes, do not check this box.)

Parent Consent for Medical Treatment

I, the undersigned parent or guardian of the above student, a minor, do hereby authorize adult workers with the youth of Washington Alliance 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 notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services. I also release The Christian & Missionary Alliance staff and volunteers from liability resulting from any accident.

Insurance Company or Group Name

Policy Number

Does the student have any allergies?
*

Yes

If the student has allergies, please list them below.

Does the student wear glasses or contacts?

Yes

Clear selection

Does the student take regular medication? If so, please explain below.

Please provide any further information about this student that you feel the ministry team needs to know.

Signature of Parent or Guardian (My signature confirms that I hereby give witness to the proper completion of this form by the minor's parent or guardian.)
*

A copy of your responses will be emailed to the address you provided.

Submit

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