Health Waiver and Parent Consent

Current Date:

T-Shirt Size

Birthday

Contact Information

Name of Student

Parent/Guardian Names

Student Email

This address will receive a confirmation email

Parent/Guardian Email

Home Phone

Cell Phone

Student Cell

Address

Medical Information

Medical Insurance Company

Policy #

Emergency Contact Name and Number

Physician Name and Number

Dentist Name and Number

Medical History

Allergies: (please list all)

Check if your child suffers from, has ever experienced, or is currently being treated for any of the following:

asthma epilepsy/seizures heart trouble diabetes frequently upset stomach physical handicap None of the above

If yes to any of the above, please explain here:

Date of last tetanus shot:

Does your child wear glasses or contact lenses?

Yes No

Please list and explain any major illnesses your child has experienced of during the last year (write NONE if nothing applies):

Should your child's activity be restricted for any reason?

Please upload a copy of your insurance card here:

Upload (8MB)

Code of Conduct

For your information, we expect each student to conform to these rules of conduct:
1) No possession or use of alcohol, drugs, or tobacco
2) No fighting, swearing, weapons, fireworks, lighters, or other explosives
3) no offensive or immodest clothing
4) no mixing of genders in gender specific rooms or facilities
5) participation with the group is expected
6) no PDA
7) respect for property
8) respect for one another and leaders
9) respect for and compliance with event schedules

By signing my name, I (the student) agree to the above code and I agree to follow what is expected of me:

Parent Consent

Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, rollerskating, skateboarding, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides, messy games, games involving food. (Note: if you desire to limit your child's participation in any event, please submit your wishes in writing to the student ministries pastor prior to that event)

Photo Consent: At times throughout the year, photos or videos may be taken to be used for social media platforms or advertising purposes for pfmsm. I consent to allow the likeness or image of my student to be used in that way at the discretion of the ministry leaders.

Yes No I would like to talk about this

I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by Renovation Students. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release Renovation Students, 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/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by Renovation Students, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we 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/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Parent Signature of Student Activity Approval, Photo, and Liability Waiver:

Date of Signature:

Health Waiver and Parent Consent

Description

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