CC PreSchool Consent/Release Form 26-27

Your name *

Email address *

Student's Name: *

Students First & Last Name

Teacher's Name:

Birthday *

I, *

Parent/Guardians Name

the *

of *

Student's Name

do hereby consent to his/her participation in the Preschool/Pre-K pårogram and its activities. This Consent and Release form applies to functions and/or activities including: *

• Transportation to and/or from field trips and outings
• Medical care for child/student in case of emergency
• Use of child’s/student’s photo individually or in a group setting. (Pictures may only be used for the purpose of ministry related bulletin boards, videos, brochures, school facebook and website, and /or church directories.)

I acknowledge that participation in the activity described above involves *

risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.
In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor.

I understand that I, *

or my designee, is responsible for the above child’s safety prior to pick up and immediately upon drop off at designated pick up and drop off points. I further understand that all drivers and passengers of Camano Chapel vans and/or personal vehicles used in any event are required by state law to sit in a state-approved booster/car seat. Seat belts must be worn at all times while vehicles are in motion.

Emergency Medical Information

Doctor's Name/Phone Number: *

Health Insurance Carrier and Policy Number: *

Person Finacially Responisble: *

Known Allergies/Medical Concerns: *

IN CASE OF EMERGENCY, *

I hereby give permission to the physician selected by the ministry staff to hospitalize, secure proper treatment for and to order injections, anesthesia, or surgery for my child as named on this form. I understand every effort will be made to notify parents or guardians of the child/student.

Home Phone Number: *

Mom's Cell Phone Number:

Dad's Cell Phone Number:

Mom's Work Phone Number:

Dad's Work Phone Number:

Alternate Emergency Phone and Name: *

I acknowledge that my legal name below serves as my signature and *

I have READ and UNDERSTAND all the information in the participation agreement above.

Please type your full Legal Name (this serves as your signature): *

Today's Date: *