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Family Info and Permission Form

VHC Family Info and Permission Form

Child and Family Information

Let us know a little about your family so we can be in ministry with you!

Parent/Guardian Information and Emergency Contacts

Medical Information

Please answer in detail if applicable or write N/A.

Parental Consent

The undersigned does hereby give permission for my child (“Participant”), to attend and participate in any Virginia-Highland Church Children and Youth Ministry activities, events, retreats and childcare during the period of September 1, 2017 – August 31, 2018. LIABILITY RELEASE: In consideration of Virginia-Highland Church allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Virginia-Highland 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 and 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 and 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 agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Virginia-Highland Church. My child/youth and I understand that seat belts must be worn at all times during transportation. PHOTO PERMISSION: I agree that Virginia-Highland Church may photograph and record my child/dependent’s likeness and activities (“Images”) during church-related activities. I grant the following rights to Virginia-Highland Church: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken. 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 Virginia-Highland Church from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.
By entering your name below, you are effectively providing your signature, giving your consent and indicating that all the information on this form is true and accurate, to the best of your knowledge.