Parent Permission Form 2023-24

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name

Relationship to Student

Address

This address will receive a confirmation email

Primary Phone

STUDENT INFO

Student Name

Birthdate

School

Grade entering in Fall 2023-24

Does your child have any medical, food or drug allergy concerns we need to know about?

Yes No

If yes, please list any here:

Does your child suffer from, ever experienced, or are they being treated currently for any of the following:

Asthma Diabetes Epilepsy / Seizure EpiPen Heart Condition Physical Handicap Stomach Issues None of the above

Has your student had any major medical illnesses or injuries during the last year?

Yes No

If yes, please explain:

Should your student's activities be restricted for any reason?

Yes No

If yes, please explain:

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 writing and attach it to this form. Medications and dosages must be listed on the Medication Form and turned into the nurse for each event upon student check-in.

EMERGENCY INFORMATION

Emergency Contact Names and Phone numbers (other than listed above)

Physician's Name

Physician's Phone

Medical Insurance Company

Policy / Group Number

PERMISSION & RELEASE INFORMATION

Please read the following and affirm your understanding of the agreements by selecting yes or no below each one.

My child has permission to travel with Cornerstone Church and/or attend all student activities from July 1, 2023 through September 30, 2024.

Yes No

I have legal custody of the student registered, a minor, and have given my consent for him/her to attend events being organized by the Church. I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release the 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 child’s involvement.

Yes No

This consent form gives permission to seek medical attention as deemed necessary and releases the Church and its staff of any liability against personal losses of named child. In the event that he/she is injured and requires the attention of a medical provider, I consent to any reasonable medical treatment as deemed necessary by a licensed provider. In such an event where treatment is required, from a provider and/or hospital personnel designated by the Church, I agree to hold such person(s) free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

Yes No

I also acknowledge that I 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 affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for the student named above. I also agree to bring my child home at my own expense should they become ill or if deemed necessary by the student ministries staff member.

Yes No

I give permission to Student Ministries to photograph and/or video tape my child for the promotional purposes of Student Ministries and/or Cornerstone Church.

Yes No

STUDENT AGREEMENTS

By placing a check next to each of the following, your student affirms they will adhere to each of the following agreements.

LIMIT Cell phone usage: Cell phones are a major distraction and will not be brought to camp or on mission trips. If a cell phone is brought to Tuesday/Wednesday evening worship, we ask that they are silenced and not used until the end of the event.

Agreed

NO Portable or Electronic Devices: Please leave electronic devices (including iPods/music players, gaming devices, etc.) at home. If these devices are brought, they will be collected and returned at the end of the event.

Agreed

CIVIL BEHAVIOR: Any student who brings drugs, alcohol, or any type of weapon will be immediately sent home. In addition, anyone who fights, threatens the safety of others, or fails to comply with event rules will be subject to removal from the event.

Agreed

PHYSICAL CONTACT: inappropriate contact of any kind at any time during Student Ministries activities will not be tolerated.

Agreed

PRIVACY: No Girls in Guys rooms / No Guys in Girls rooms.

Agreed

BIG 5 Proverbs: Show respect! Listen! Be flexible! Have a good attitude! Be where you're supposed to be, when you're supposed to be there, doing what you're supposed to be doing!

Agreed

Parent Permission Form 2023-24

Description

Please Fix the Following