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2020 Youth & Children Activity Authorization:Medical/Liability Release Form on Wednesday, January 1, 2020

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Please fill in all fields. This form will last as your consent for a calendar year, ending 12/31/2020.
*Parent's First Name:
*Parent's Last Name:
*Child's Gender:
*Is your child in Youth Group or Children's Ministry?:
*Child's Date of Birth (mm/dd/yyyy):
*Grade:
1st LEGAL GUARDIAN
*1. First and Last Name:
*Relationship to the Participant:
2nd LEGAL GUARDIAN (if applicable)
2. First and Last Name:
Relationship to Participant:
EMERGENCY CONTACT INFORMATION
*Primary Emergency Contact Name and Phone:
Secondary Emergency Contact Name and Phone:
HEALTH INSURANCE INFORMATION
*Health Insurance Provider:
*Policy Number:
*Name of the Policy Holder:
*Medical Insurance Company Phone Number
Any other information such as a group number we would need for your insurance company?
MEDICAL HISTORY
*I certify that the above named participant is in good health and able to participate in all activities.
If you answered NO to the above, please specify limits of participation.
*Any allergies to food or medications?
If you answered YES to the above, please specify allergies.
Is the participant currently under a doctor's supervision for any of the following?
If you checked ALLERGIES NOT LISTED above, please specify allergies.
Any other condition or special care need we should be aware of?
*Is the participant taking any prescription medications?
If you answered YES to the above, please specify medication.
(Group leaders must be informed of any prescription medication brought by youth, with clear information as to proper use and dosage. If medication is as needed, your child must understand the symptoms of their condition and know when to ask for help).
Please check all over-the-counter medications you will NOT allow to be dispensed to this participant:
PHYSICIAN INFORMATION
*Family Physician (first and last name):
*Physician Phone Number:
MEDICAL AND PARENTAL CONSENT AND RELEASE
MEDICAL CONSENT: As the legal guardian, if the participant is a minor under the age of 18, I hereby attest that I have read this complete document; all information provided is complete and true; I have legal standing to make decisions which affect the rights of the above-named participant; and, I understand and consent to all terms outlined in this document. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to Youth Ministry activities and travel, understanding that some activities may pose a risk of injury. I will not hold liable First Presbyterian Church, Augusta, its employees, agents and event/youth group leaders for any injury, illness or property damage involving the above-named participant, no matter how caused. Whenever deemed necessary by group leaders, I authorize the calling of a doctor and/or the providing of other medical services and, unless covered by insurance, agree to pay for same. If the above-named participant is incapacitated or under age 18, I do hereby authorize group leaders as agent for the undersigned, to consent with respect to such participant to any x-ray examination, anesthetic, medical, dental or surgical diagnosis and/or treatment, and hospital care which is deemed advisable by a state-licensed physician or surgeon.
PARENTAL CONSENT (for minor under age 18): As legal guardian of the above-named minor under the age of 18, I give my permission for him/her to be involved in the Youth Ministry program(s) of the First Presbyterian Church, Augusta, GA. I am familiar with the general goals and purpose of the program(s). I understand I will be notified of any special activities and trips away from church, including location, form of travel and cost. Should my child choose to attend such activities, I agree to send them with the appropriate clothes, personal items and money needed. Unless I have made special arrangements with a group leader, transportation to/from church or group activities, or to a common drop point for group travel, is the child and parent's responsibility. If my child needs to be sent home for any reason, including behavior problems or medical reasons, I agree it will be at my expense.
PHOTOGRAPHY, DIGITAL, VIDEO RELEASE: I hereby grant the Church and its representatives permission to use, without compensation or restriction, photographs, digital images and videotape images in which the participant appears, in any manner whatsoever such as, but not limited to: publication, display, advertising, slide shows, etc.
CONFIDENTIALITY: I understand that health information of this form will only be shared, as needed, with group leaders, Church staff and medical professionals to safeguard and support the participant. This information will not be publicly disseminated or released to outside organizations. However, since it is common practice for the Church to publish a participant's address, phone number and/or birthday on the group's roster, if they actively participate in the group, I authorize the Church to publish such information on a local (or event) roster.
LIMIT OF CONSENT: The consent outlined in this Youth and/or Children's Activity Authorization/Medical/Liability Release, concerning my child's participation in Youth and/or Children's Ministry activities, expires on December 31st. It is my responsibility to notify the group leaders or minister if any information changes or I decide to withhold consent.
*

I hereby attest that I have read this complete document; all information provided is complete and true; I have legal standing to make decisions which affect the rights of the above-named participant; and, I understand and consent to all terms outlined in this document.

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