Today's Date:

Teen’s Birthday

The undersigned who resides at and who is one of the parents/legal guardians of a minor who resides at hereby authorizes any responsible adult bearing this written authorization, into whose said care the above mentioned child may require an X-ray, examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care, to be rendered to said minor under the general or special supervision and upon the advice of a licensed physician and/or surgeon and to consent to an X-ray, examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a licensed dentist. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power on the part of said adult person to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician or dentist in the exercise of his/her best judgment may deem advisable.

Home Phone:

Cell Phone: (1)

Work Phone:

E-mail Address:

Name & Phone number of emergency contact (not yourself):

Medical Insurance Company:

Policy Number:

Group Number:

Name of Parent/Guardian who is policy holder:

Please list all prescriptions (over the counter or by prescription) that your child is currently taking along with the dosage, quantities and times. Please be specific. If it is needed while they are at an activity or overnight trip PLEASE HAVE IT IN THE ORIGINAL CONTAINER.

I hereby give permission for my child to receive and take, if needed, over the counter medicine. Example - Advil, Tylenol, cough medicine, etc...YesNo

I hereby give permission for my child to attend and participate in the teen activities listed on the CBC teen calendar. If there is a change to the schedule I expect to be notified by email in advance of the activity. YesNo

Past or current health issues/allergies that could be important for the physician to know about for proper diagnoses and treatment:

Please list any PHYSICAL activities that you DO NOT want your child to participate in.(example: they had knee surgery recently and should not participate in….)

MEDICAL AND LIABILITY AGREEMENT:

In consideration of the child’s participation in ministries and activities, as well as transportation to and from ministries and activities of Calvary Bible Church located at 603 Wilson Ave. Hanover PA 17331 I, individually and on behalf of any other parent or guardian of the child named agree to release, indemnify, defend, and forever discharge Calvary Bible Church, the board of elders, employees, paid staff, volunteer staff, and all representatives of and from any and all claims, losses, injuries, (up to and including death), demands, rights, and causes of action which may result from participation of the child. I/We know that children may be injured, sometimes seriously, up to and including death. I/We certify that the child named is physically and medically able to participate in the activities (except as noted) and related activities to the best of my/our knowledge, information, and belief. In the event of an emergency, every effort will be made to immediately contact the parent or guardian at the phone number(s) listed. If I/we cannot be reached at the phone number(s), I/We give permission to the physician selected by Calvary Bible Church to hospitalize, secure proper treatment for and order injection(s), anesthesia, or surgery for the child as the physician(s) sees fit. I/We release Calvary Bible Church, and their employees, volunteer and paid staff, affiliates, representatives, directors, elders and officers for any medical treatment provided hereunder. I/We agree to be completely responsible for any and all treatment and related costs for medical and dental services provided pursuant hereto. Appropriate photographs and/or video recordings may be taken of the child while participating in any related activities. These photos and/or video recordings may be published in Calvary Bible Church’s materials such as in/on bulletin boards, flyers, mailers, web site, and the like. I/We give our permission to Calvary Bible Church to use such photos or recordings and release and hold harmless Calvary Bible Church for any action taken as stated herein, from any and all claims, losses, or injuries which could or may result from such publications, including from any acts of negligence or carelessness related thereto.

This authorization is effective immediately and will remain in effect for a time limit not to exceed 12 months from the date below, unless revoked in writing and delivered to the ministry leader.

Unless otherwise directed, I hereby also authorize Calvary Bible Church to release my child to his own authority at the conclusion of the ministry or activity.

Appropriate photographs and/or video recordings may be taken of the child while participating in any related activities. These photos and/or video recordings may be published in Calvary Bible Church's ministry materials such as in/on bulletin boards, flyers, mailers, web site, in-house video and the like with no personal information listed.

Published on Calvary Kids Facebook page

Livestreaming on Calvary’s YouTube

Date:

Contact Information:

Robert T. Greene                    717-451-6876 (cell)
Pastor of Youth                       717-630-2624 (home)
Calvary Bible Church              717-632-3954 (church)
rgreene@cbc-hanover.org

YES,I WOULD LIKE TO RECEIVE ELECTRONIC EVENT & CALENDAR REMINDERS?

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