Children & Student Ministries Participation Form 2022-2023

Student Information

Name of Child/Student:

Gender: M/F

Age:

Birthdate:

Grade:

Name of School:

Student Email:

Student Cell Phone:

I want my child to be involved in the following programs:

Parent/Guardian Information

Family Address:

City, State, Zip

Parent/Guardian #1:

Home Phone:

Cell Phone:

Work Phone:

Parent/Guardian's Email:

This address will receive a confirmation email

Parent/Guardian #2:

Relation to Child:

Cell Phone:

Work Phone:

Parent/Guardian's Email:

Emergency Contact

Emergency Contact:

Emergency Contact Phone:

Relation to Child:

Emergency Release

If different than the above named, I/we give permission for my/our child to be released to:

Name(s)

Phone#

Regarding San Marino Community Church's permission to use my son/daughter(s) image in any media publications, electronic or printed.

I DO NOT grant San Marino Community Church permission. I DO grant San Marino Community Church permission.

Are you a member of SMCC?

YES NO

If not, are you interested in becoming a member? YES NO

Health or Special Needs (Check as appropriate)

My son/daughter(s) have no special health needs that the staff should be aware of and is/are not on any kind of medication.

My son/daughter(s) have no special health needs that the staff should be aware of and is /are not on any kind of medication. Yes - My son/daughter has the following allergies/special need(s) – please modify my son/daughter’s activities. (Examples: epilepsy, heart trouble, diabetes, etc. Please provide specific instructions including current medication, frequency, and dosage)

Minor's Name:

Allergies/Special Needs:

Doctor's Name:

Doctor's Phone Number:

Health Insurance Company:

Policy Number:

Parent/SMCC Staff & Program Leader Contract:

We/I understand that SMCC staff and program leaders are not prepared to provide care for children who are excessively disruptive, pose a threat to themselves or others, or who exhibit an inability or unwillingness to control his/her impulses. In the event that our child exhibits signs that are beyond his shadow's capabilities, we agree to seek further professional assistance for behavior correction, create a plan, and re-sign SMCC's behavior contract upon admittance to SMCC childcare offerings.

Please Print Name:

WAIVER/GENERAL RELEASE FOR A MINOR (through September 2023)

Please Print Name:

I (above named parent) authorize(s) San Marino Community Church, it’s agents, employees, officers, directors and volunteers (herein known as SMCC) in whose care the minor child has been entrusted by me/us, to consent to any x-ray examinations, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to the minor under the general care and special supervision of a licensed physician under the California Medical Practice Act and/or by a licensed dentist. It is understood that this authorization is given in advance of any special diagnosis, treatment or hospital care being required. It is given to provide authority and power on the part of SMCC to give specific consent to any and all such diagnosis, treatment or hospital care which a treating physician and/or dentist in the exercise of his/her best judgment may deem advisable in the event of illness or injury of the minor child. This authorization is given pursuant to the provisions of California Family Code, Section 6901-6910. This authorization shall remain in effect through September 30, 2023 unless sooner revoked by the undersigned in writing delivered to SMCC. This also releases SMCC, it’s agents, employees, officers, directors and volunteers (herein known as SMCC) from any and all costs and expenses, including but not limited to, attorney’s fees, reasonable investigative and discovery costs, court costs, and all other sums which SMCC may pay or become obligated to pay on account of any, all and every demand for, claim or assertion of liability or any claim or action founded for, arising or alleged to have arisen out of the activity for which this authorization is given or the use of real property belonging to SMCC by any action or omission by the minor child.

Liability Release: I/We agree to waive all claims against SMCC, it’s agents, employees, officers, directors and volunteers harmless from any and all liability claims that may arise out of or in connection with my child’s/children’s participation in this ministry and its activities.

Transportation Release: I/We are aware that students will be transported to and from events in a church, and/or rental and/or private vehicles. A completed (signed and returned) Field Trip Permission form will be mandatory for any event where minors will be transported off campus.

Insurance Release: I/We understand that SMCC’s insurance begins where the individual’s health and accident policy terminates.

Personal Belongings Release: I/We understand that SMCC is not responsible for personal belongings (including but not limited to cell phones, clothing, etc.)

Discipline Release: I/We fully understand that each participants are to abide by all rules and regulations governing conduct during the various activities/trips. In the event of repeated student misconduct, I/We authorize the staff to send my child home at my (parent’s/guardian’s) expense.

Date:

Description

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Children & Student Ministries Participation Form 2022-2023

Description

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