Central Presbyterian Church

“Blue Form”: Child/Youth Registration and Medical Information/Release

Christian Education Programs

September 1, 2009 to August 31, 2010

 

YOU MUST USE ONE FORM FOR EACH CHILD/YOUTH (C/Y)

 

 

C/Y’s Name: ____________________________________________________________ Date of birth ___/___/___

 

School: _______________________________ Grade: ____________ (Fall of 2009)  Age:­­­­­­­­­­­­­­________ (Fall of 2009)

 

Parent(s)/Guardian(s) Name(s): _______________________________, ___________________________________

 

Address: _________________________________________________________________, IN , _______________

 

Home Phone: _______________________                (F)Work Phone: ________________________

 

(M)Work Phone: _________________________    Cell Phone  (whom): _____________________________        

 

E-mail addresses: ______________________________________________________________________

 

Non-custodial Parent (if applicable) or Emergency Contact (non-member of household):_________________________

 

Address (w/ Zip Code): __________________________________________________________________________

 

Home Phone: ______________ Work Phone: _______________  E-mail address: ______________________________

 

Names, ages and grades of brothers and sisters:

 

Programs for which you wish to register this child/youth.  [Check all that apply]

 

Childcare:                                                                            Sunday School classes:     

____       Infant (birth to 2 yrs)                                          ____       2-3 yr olds

                                                                        ____      Pre-K-K (ages 4-6)

Sunday Evening Programs:                                              ____       Celebration Station (Grades 1-5)

____       “Youth Group” (Grades 6-12)                           ____       Middle School (Grades 6-8)

                                                                                                ____       High School (Grades 9-12)

                               

 

Is there anything special about your child that you would like us to know, (e.g., custodial arrangements, persons to whom your child should not be released?) ________________________________________________________________________________________________________________________________________________________________________________________________________

 

PHOTO/PUBLICITY WAIVER

 

I hereby grant to Central Presbyterian Church (“Church”) the right and permission to use any photographs or video it has taken of my child or youth named above for any purpose relating to Church related activities, programs, or events depicted in media produced, published, or distributed by the Church now or in the future.  I hereby release and discharge Church from any and all claims and demands arising out of or in connection with the use of the photographs or videos, including any and all claims for libel or invasion of privacy.

 

_____________________________________         ___________________________________

(Parent or Legal Guardian’s Signature)                     (Date)

OVER


MEDICAL INFORMATION/RELEASE

 

Allergies:                     _________________________________________________________________

                                   

Other Health Issues:   _________________________________________________________________

                                                           

Prescriptions/reason:   _________________________________________________________________

           

Child’s Primary Physician: __________________________ Telephone No: _________________

Health Insurance Carrier: ___________________________  Policy No.:____________________

Child’s Dentist: __________________________________               Telephone No:_________________

Dental Insurance Carrier: __________________________   Policy No.:____________________

 

Parents are responsible for updating the information in this form as appropriate. 

 

The undersigned hereby agree and consent to the administration of over-the-counter medicines (e.g., Tylenol, Pepto-Bismol) to the above named child or youth for minor ailments. In case of emergency, I (we) authorize the adult in charge to consent to medical care, or dental care, or both, for my/our minor child. For purposes of this consent, the term “medical care” shall include, but not be limited to, X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care under the general or special supervision and upon the advice of or to be rendered by a licensed physician or surgeon. For purposes of this consent, the term “dental care” shall include, by not be limited to, X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care by a licensed dentist. I (We) further hereby authorize any and all of my child’s health care providers to release and/or disclose any and all protected health information relevant to the diagnosis and treatment of any physical, mental, and/or emotional condition of my child to the adult in charge. This Authorization shall extend to and include, but not be limited to my child’s medical history, including specific progress notes regarding any problems that would impact any surgery or procedures, progress or outcome, results of relevant diagnostic or laboratory tests, and, where necessary, my child’s entire medical record. I/We understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the above named person and may no longer be protected by federal or state law. I/We understand that information used or disclosed pursuant to this consent may be subject to re-disclosure by the above named person and may no longer be protected by federal or state law. 

 

__________________________________    __________________________________

(written)                                                          (date)

__________________________________    __________________________________

(printed)                                                          (contact number)

 

 

BLANKET PARENT/GUARDIAN PERMISSION SLIP

FOR LOCAL OFF-SITE ACTIVITIES 2009-2010

 

Central Presbyterian Church uses a blanket permission slip for off-campus activities for each Church School year. This policy applies to all children and youth in grades three through twelve.  This form, along with an annual Consent to Medical Treatment form must be on file for your child or youth to be included in any such events.

 

I hereby give permission for my child, _______________________________, to participate with the Central Presbyterian Church children or youth groups, at any and all of-campus, church approved events beginning _9/1/2009_____ and extending to __8/31/2010_____.  I will notify the specific group leaders if my child does not have permission to attend a specific event.  I have completed the annual Consent to Medical Treatment form and it is on file in the church office.  I accept responsibility for payment of any and all expenses required for a specific local, off-site event. 

 

In signing this form I understand that I will hold neither the supervisory adults nor Central Presbyterian Church or any of its agents liable for injuries or damages sustained by my child/youth during any off-campus, church-sponsored event.

 

A SEPARATE PERMISSION FORM SHALL BE REQUIRED FOR ANY OVERNIGHT TRIP OR EVENT AND ANY EVENT OR TRIP THAT REQUIRES TRANSPORTATION TO A SITE OUTSIDE OF TIPPECANOE COUNTY, INDIANA.

 

_____________                                  ___________________________________________

Date Signed                             (written)

                                                ___________________________________________

                                                (printed)