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Give
Annual Parental consent
Annual Medical Consent & Liability & Photo Release Waiver
Child's Information:
First Name
Last Name
Phone Number
Date of birth
Month
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2024
Address
Apartment, suite, etc.
City
State
Postal / Zip Code
Parent Information
First Name
Last Name
Email
Phone Number
Emergency Contact if Parent is unreachable
Emergency Contact Phone
Doctor's Name
Doctor's Phone
Family Insurance Provider
Provider Group #
Has your child had:
Appendicitis
Heart Ailments
Asthma
Scarlet fever/hay fever
Rheumatic Fever
Piomyelitis Diabetes
Epilepsy
Fainting Spells
Significant Injuries or Operations
None
Is your child experiening any of the following:
Contagious Disease
Activity restriction for any reason
Allergy to Medication
Other medical condition
None
If yes to previous questions, please explain
Medications currently taking, dosage schedule
Allergies
Permission for medical treatment
MEDICAL TREATMENT: In the event my son/daughter becomes ill or sustains injury while in the care of or under the supervision of Neighborhood Church, or any of its officers or leaders, they are given permission to administer first aid for his/her relief. Consent is also given to admit him/her to any hospital and for all medical, surgical, diagnostic, and hospital procedure or treatment as may be performed or prescribed, including the administration of such drugs or medicines, by a physician for him/her when such treatment is deemed immediately necessary or advisable to safeguard my child's health and it is not advisable or practical to return him/her to us or to receive our instruction for his/her care. I waive my right to be informed and consent to said treatment.
Liability & Photo release and consent to participation
LIABILITY RELEASE: I/We, the undersigned am aware that the program my child/teen is involved in is operating as a ministry of Neighborhood Church of the Assemblies of God, in Sunnyside, Washington. Moreover, that the wide range of activities offered my child/teen sometimes involves activities at locations other than the church. With the above in mind I/we hereby give permission/consent for my/our child to participate in all activities for the year beginning January 1, 2024 through January 1, 2025 and for their transportation to and from the activity which I/we understand is provided for by volunteers of Neighborhood Church. I/we do also hereby consent and agree to hold harmless/release Neighborhood Church and its agents, employees, and volunteer assistants from any and all liability whatsoever arising out of injury, sickness, or damage which may be sustained by my son/daughter during the course of his/her involvement in said activities. I give my consent:
Yes
No
PHOTO RELEASE: With this form I give my permission and consent for the use of photos/videos of my child (listed above) on the website of Neighborhood Church and its publications. I will not expect any payments or other form or renumeration in exchange for the use of these photos/videos. I understand that this consent will remain active until I deliver a written request to discontinue it.
Yes
No
Signature
Date Input
Month
January
February
March
April
May
June
July
August
September
October
November
December
Date
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
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2022
2023
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