Parent(s) / Legal Guardian(s)
 
* Or Legal Guardian
* Or Legal Guardian
*
* Include Area Code - No Spaces
*
 
Or Legal Guardian
Or Legal Guardian
Include Area Code - No Spaces
 

Emergency Contact (in the event a Parent or Legal Guardian cannot be reached)
 
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Primary Residence of Child/Student
 
* Primary Residence of Child
* Primary Residence of Child
* Primary Residence of Child
* Primary Residence of Child
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Parental Consent
1. Release of Liability. The undersigned does hereby give permission for our (my) child(ren), as named on reverse, to attend and participate in any on and offsite children’s and student ministry events sponsored by or involving Remembrance Church (“RC”). In consideration for the agreement by RC to permit my child(ren)’s participation, I, for myself, my minor child and for the child(ren)’s other parent and/or guardian(s), hereby release, waive, discharge, and covenant not to sue RC, and its officers, directors, employees, agents, volunteers, of and from all liability, loss, claims, demands, possible causes of action, court costs, attorneys' fees and other expenses arising from any lawsuit that may otherwise accrue from any loss, damage or injury to my child(ren)’s person or property in any way resulting from or connected with my child(ren)’s participation in any activity including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons. I further agree to indemnify and hold harmless RC and its employees, agents and volunteers from any loss, liability, damage or cost they may incur incident to my child(ren)’s participation in any activity. If any claim or lawsuit is brought, this release shall be enforced under Michigan law. Any claim or lawsuit must be brought within 180 days from the date of the alleged loss, damage or injury.
2. Photo & Vehicle Release. I give permission for photo and video of my child(ren), which may be taken during any ministry activity, to be used for publication purposes and/or to appear on the church websites, social media, or other publicity. The undersigned does also hereby give permission for our (my) child(ren) to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by RC.
3. Consent to Medical Treatment. 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 dental services rendered to the aforementioned child(ren) pursuant to this authorization. Should it be necessary for our (my) child(ren) to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. This authorization shall be effective for 12 months from signed date unless earlier revoked in writing.
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Health Insurance
 
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Child/Student 1
 
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*
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Child/Student 2
 
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Child/Student 3
 
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Child/Student 4
 
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