SURGE Student Ministries Minor Consent Form

New Love In Christ Church 6003 Jonestown Road Harrisburg PA 17112 (717) 540-8439 Please print in ink. Childs Name: _______________________________________________ DOB: _____ / _____ / _____
Last First MI Month Day Year

Home Address: ____________________________________________

Number Street

Age: _____

Male Female

____________________________________________
City State Zip

Home Phone: (____) ____ - ______

Parents or Legal Guardian

Name: _____________________________________ Mother Father Guardian Name: _____________________________________ Mother Father Guardian Home: (____) ____ - ______ Cell: (____) ____ - ______ Work: (____) ____ - ______ Pager: (____) ____ - ______ Work: (____) ____ - ______ Pager: (____) ____ - ______

Home: (____) ____ - ______ Cell: (____) ____ - ______

Emergency Contact
Name: _____________________________________ Home: (____) ____ - ______ Cell: (____) ____ - ______ Work: (____) ____ - ______ Pager: (____) ____ - ______

Medical Treatment
Insurance Company: ___________________________________________ Family Physician: ______________________________________________ Dentist: ______________________________________________________ Policy #: _____________________ Office Phone: (____) ____ - ______ Office Phone: (____) ____ - ______

Medical History
If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in at the conclusion of this form.

Physical Limitations: Allergies:

(pollen, meds, food, insects)

Yes Yes Yes Yes

No No No No

If yes, please explain: ___________________________ If yes, please explain: ___________________________ If yes, please explain: ___________________________ If yes, please explain: ___________________________

Dietary Requirements: Current Medications:

Year of last Tetanus Shot: _______

[Medical History continued]

1
(If necessary, attach an additional page for more information)

Check the following areas of concern for your child:

1. For your childs safety and our knowledge, is your child a good fair non swimmer. 2. Does your child suffer from, has ever experienced, or is currently being treated for any of the following: asthma physical handicap diabetes frequently upset stomach heart trouble epilepsy/seizure disorder diabetes

3. Does your child wear glasses contact lenses? 4. Explain any major illnesses the child experienced during the last year: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. Should your childs activities be restricted for any reason? Activities may include, but are not limited to: cookouts, boating, swimming, basketball, roller-skating, rollerblading, games in the park, soccer, ice skating, volleyball, softball, baseball, camping, canoeing, hiking, biking, concerts, Bible studies, miniature golf, hayrides. Please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________

Parental Permission and Medical Consent with Liability Release

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases the Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by New Love In Christ Church. I/We understand there are inherent risks involved in any ministry or athletic event, and hereby release the New Love In Christ Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our childs involvement. In the event he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/We agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/We affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the childrens ministries staff/volunteer member. ______________________________________________________________ has my/our permission to attend all
Name of Student

activities sponsored by New Love In Christ Church from

12
Month

/
Day

31 /
Year

2011 to
Month

12
Day

/ 31 / 2012
Year

(This form may be revoked at any time before the expiration date with written notice to the Organizer.)

Parent/Guardian Signature: ________________________________________________ Date: _____ / _____ / _____

Month Day Year