First Covenant Church
Permission/Waiver Form

Full Name of child or Adult Participant (please print): ____________________________________________
Parent(s)/Guardian(s) Name(s): ________________________________________________________________
Address: ________________________ City: _______________ State: ____________ Zip: ________________
Home Phone (_____) _______________________  Work Phone (_____) ______________________________
Cell Phone (_____) ________________________   Email Address ___________________________________ 
Age of Child ______________  Birth Date __ /__ /__  Academic Grade ________________________

Functions and Activities:
    It is my understanding that in the programs and recreational and other activities of First Covenant Church is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
I understand that this waiver form is good for one year from the date that it is signed.

Release of Liability:
    By signing this Permission/Waiver Form, I expressly warrant that the child named above or, I, if I and a participant, am capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release First Covenant Church and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have in that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability is also intended to cover all claims that members of the child's or family or estate, heirs, representatives, or assigns may have against First Covenant Church or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless First Covenant Church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

Special Events and Field Trips:
    I understand that the child named above or I will be participating in First Covenant Church activities. I understand that during these events my child/ward or I, if I am and adult participant, may take part in activities such as: biking, skiing, swimming, hayrides, tubing, camping, group games and other activities consistent with purposes of the church.

Publicity:
    On occasion, First Covenant Church takes photographs or makes and audio or videotape recording of children and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in First Covenant Church publications or advertising materials, video projection screen, or on the First Covenant Church's website to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above or me, if I am participating, to be used, distributed or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotapes, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media.
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Allergies/Medical Conditions/Medications/Other: __________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date of last tetanus shot: __ /__ /__

Health Insurance Information:
Insurance Company: _______________________________________ Phone: (___) _______________________ 
Street: _______________________ City: ____________________ State: _________ Zip: _________________
Policy # 	 
Policy Holder's Work #: (_____) 	          Policy Holder's Date of Birth: __ /__ /__
Emergency Contact: __________________________________          Home#: (_____) _________________
Relationship: ________________________________________          Cell#: (_____) __________________

First Aid and Emergency Medical Treatment:
    I recognize that there may be occasions where the child named above or I, as a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of First Covenant Church to seek and secure any needed medical attention or treatment for the child named above or me, if I am a participant, including hospitalization, if in the agent's opinion such need arises. If a situation like this should arise, I agree to pay all fees and costs from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery. Again, I agree to pay for all medical treatment.
 
Agreement to Transport Home:
    I/We the undersigned, are the parent(s) or legal guardian(s) of ________________________ (participant’s name), a minor, and have given my/our consent for him/her to attend First Covenant Church events. I/We understand that First Covenant Church, its ministers, leaders, employees, volunteers, or agents may need to send a participant home due to illness or as the result of disciplinary action. I/We understand if the participant named above is dismissed from any First Covenant Church event, he/she will be transported home at my/our expense. (First Covenant Church, its ministers, leaders, employees, volunteers, or agents will make contact with the parent(s) or guardian(s) to arrange such transportation.)
Again I understand that this waiver form is good for one year from the date that it is signed.

__________________________________________		___________________________________________
    Printed name of parent and/or legal guardian			     Printed name of parent and/or legal guardian

__________________________________________		___________________________________________
Signature 				   Date 		Signature 				     Date