Shepherd of the Bay Lutheran Church
Parental Consent Form
Name_______________________ Age________ Birthdate_____________
Address___________________________________________ Home phone_________
Parent(s)/Guardian business phone(s)__________________________
Cell phone_____________________ E-mail__________________________
To Whom It May Concern:
The undersigned does hereby give permission to our (my) child ____________________
To attend and participate in activities sponsored by Shepherd of the Bay Lutheran church throughout the year_2019-2020.
In the event of an emergency, we (I) authorize an adult, in whose care the minor has been entrusted, to consent to any 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, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dentist services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons, the undersigned shall assume all transportation costs.
Our (my) child understands that he/she must abide by the rules established by the youth group leaders. In the event of his/her failure to abide by the rules, we (I) understand
that we (I) will be contacted and be expected to come and pick him/her up.
The undersigned also does hereby give permission for our (my) child to ride any vehicle designated by the adult in charge whose care the minor has been entrusted while attending and participating in activities sponsored by or associated with Shepherd of the Bay Lutheran Church.
Hospital Insurance____Yes ______No Policy #_______________________
Insurance Company______________________________________________
Participant Signature___________________________Date______________________
Father Signature_______________________________ Date______________________
Mother Signature______________________________ Date_____________________
Legal guardian Signature________________________ Date______________________
Emergency Phone #’s______________________________________________
Please list allergies, special medical problems, or medications your child may have on the reverse side. If any medication needs to be administered to a child, the parent/guardian should complete a medication consent form available by request. Thank you.
I will drop off and pick up my child in their designated room each week (preschool-1 grade) as requested in the church policy. I understand that if my child is in grade 2 or higher they can arrive independently and will be dismissed at the end of class to meet me at a designated area unless I give a written statement saying otherwise. _________Initials.
For the Wonderful Wednesday Summer Program I will sign my child in and out with the person in charge.______Initials.
The following people have permission to pick up my child._____________________________
I will call if someone other then my self or the above listed cannot be there.
I am willing to transport children in my private vehicle if needed. I have included my driver’s license number, expiration date, and proof of insurance liability coverage. I understand the law regarding child transportation safety.______Initials.
I understand that photos or videos of my child participating in a program may be displayed or used at church events,Facebook, or on the church web page..________Initials.
Parental Consent Form
Name_______________________ Age________ Birthdate_____________
Address___________________________________________ Home phone_________
Parent(s)/Guardian business phone(s)__________________________
Cell phone_____________________ E-mail__________________________
To Whom It May Concern:
The undersigned does hereby give permission to our (my) child ____________________
To attend and participate in activities sponsored by Shepherd of the Bay Lutheran church throughout the year_2019-2020.
In the event of an emergency, we (I) authorize an adult, in whose care the minor has been entrusted, to consent to any 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, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dentist services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons, the undersigned shall assume all transportation costs.
Our (my) child understands that he/she must abide by the rules established by the youth group leaders. In the event of his/her failure to abide by the rules, we (I) understand
that we (I) will be contacted and be expected to come and pick him/her up.
The undersigned also does hereby give permission for our (my) child to ride any vehicle designated by the adult in charge whose care the minor has been entrusted while attending and participating in activities sponsored by or associated with Shepherd of the Bay Lutheran Church.
Hospital Insurance____Yes ______No Policy #_______________________
Insurance Company______________________________________________
Participant Signature___________________________Date______________________
Father Signature_______________________________ Date______________________
Mother Signature______________________________ Date_____________________
Legal guardian Signature________________________ Date______________________
Emergency Phone #’s______________________________________________
Please list allergies, special medical problems, or medications your child may have on the reverse side. If any medication needs to be administered to a child, the parent/guardian should complete a medication consent form available by request. Thank you.
I will drop off and pick up my child in their designated room each week (preschool-1 grade) as requested in the church policy. I understand that if my child is in grade 2 or higher they can arrive independently and will be dismissed at the end of class to meet me at a designated area unless I give a written statement saying otherwise. _________Initials.
For the Wonderful Wednesday Summer Program I will sign my child in and out with the person in charge.______Initials.
The following people have permission to pick up my child._____________________________
I will call if someone other then my self or the above listed cannot be there.
I am willing to transport children in my private vehicle if needed. I have included my driver’s license number, expiration date, and proof of insurance liability coverage. I understand the law regarding child transportation safety.______Initials.
I understand that photos or videos of my child participating in a program may be displayed or used at church events,Facebook, or on the church web page..________Initials.