Please list each child and the school they attend.
Please list at least two emergency contact people and include their name, phone number, and relationship to child.
Please provide the Company Name, Phone Number, Policy/Group #, and Policy Holder's Name.
Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction? (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?
List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription and non-prescription medications, herbal supplements, and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian's expense if they do.
Please include the medication name, dose, reason for medication, and dispensing instructions.
Please answer in detail if applicable or write N/A. List any medical conditions the youth has (asthma, diabetes, epilepsy, etc.)
Please answer in detail if applicable or write N/A. List any allergies (drug/medicine/food/environment) and the severity and type of reaction:
Please answer in detail if applicable or write N/A. Explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.
I agree that Battle Creek Community Church may photograph and record my child/dependent's likeness and activities during church-related activities. I grant the following rights to Battle Creek Community Church: permission to use and re-use, publish, and re-publish, and modify or alter the image(s) taken during the program. Use of the images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the internet, and worldwide in perpetuity for the purposes stated above.
I waive my right to inspect or approve any editorial text or copy that is used in connection with the images and release and discharge Battle Creek Community Church from any claims arising out of the use of the images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by checking YES below. I am over the age of 21 and have the legal capacity to sign the release.
By checking YES I hereby give permission for my child to attend and participate in any Battle Creek Community Church Student ministry activities, events, retreats, and childcare.
LIABILITY RELEASE: In consideration of Battle Creek Community Church allowing participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I do hereby release, forever discharge and agree to hold harmless, Battle Creek Community Church its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.
MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth under this authorization.
EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibility. Students are expected to stay for the duration of any events or programs; however, should a student need to leave early this will need to be communicated and cleared between the Ministry Leader & Parent/Guardian (the undersigned).
TRANSPORTATION PERMISSION: The undersigned also permits my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Battle Creek Community Church.
Student Ministry Programming will always cancel if/when BCPS and/or Pennfield School districts cancel school or evening activities due to inclement weather. Cancellations will always be posted in the Church Center group and Facebook group.
By typing your name below you agree to the policies of BCCC Student Ministry and give consent for your child to participate in Student Ministry Programming and Trips.
