Heath Church of Christ

Family Ministry Permission Slip

HFM PERMISSION FORM: This blanket permission slip is valid for one year from the date of submission.

I am a parent filling out this form

I am a guardian filling out this form

Other

If "Other" please state your relationship to the child.

Child's First Name

Child's Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Release from Liability

The undersigned is the parent or legal guardian of the Minor named above (hereinafter referred to as "Minor"). The undersigned desires for said Minor to attend and/or participate in ministries, events, programs, functions, and activities (hereinafter referred to as "Activity"), sponsored by Heath Church of Christ (hereinafter referred to as "Church"). I understand and acknowledge that Church will allow the Minor to participate in any Church activity without releasing and holding the Church harmless from any liability arising out of the Minor attendance and/or participate in that Activity, including the Minor's transportation to, during and from the Activity, if provided by the church. I have or will investigate the risks involved with the Minor's attendance and/or participation in any Activity, and further as the parent or legal guardian of said Minor assume any and all risks of personal or bodily injury to said Minor or property damages associated with said Activity. By signing this document, on behalf of myself and the Minor, I hereby release and forever discharge the Church, its ministers, officers, directors and employees, agents and any parties volunteering on behalf of the Church from all claims, damages, cost or expenses of any kind arising out of or related to the Minor's attendance or participation in any Church Activity. I understand that this document is full complete release of all claims for personal or bodily injury and property damage which the Minor might sustain as the result of the Minor's attendance and/or participation in any Church Activity regardless of the specific cause thereof, and I further understand that in the event of such personal or bodily injury to the Minor, or property damage, that I cannot seek, on behalf of the Minor or myself, any type of recovery of reimbursement whatsoever from the Church or their ministers, officers, directors, employees, agents or any parties volunteering on behalf of the Church.

I AGREE TO THE TERMS LISTED ABOVE

Medical Release

In the event of an emergency where medical treatment is required I give my permission to the church staff or sponser to obtain the services of a licesnsed physician for the Minor listed above. Please attempt to notify me immediately concerning ant such emergency.

I AGREE TO THE TERMS LISTED ABOVE

Emergency Contacts

Please list numbers in order of priority.

First Emergency Contact

Second Emergency Contact

Third Emergency Contact

Insurance Information

Insurance Company Name

Account Number

Allergies

Comments or Medical Notes

Signature

Date of Signature