Mt. Zion Child Release & Registration Form 2023-2024

I am registering my child for:

Please choose the activity or activities your child will be attending

AWANA 2023-2024 (Pre-K-5th grade, Wednesdays -Sept-May) KidZone (Nursery-5th grade, Sundays) Parents' Night Out (Friday, February 16, 2024, 5PM-9PM at Mt. Zion)

Child's Information

Name

Grade Next School Year (2023-2024)

Date of Birth

Gender at Birth

Address

T-Shirt Size (Free)

Parent/Guardian Information

Parent/Guardian Name #1

Cell Phone

This address will receive a confirmation email

Parent/Guardian Name #2

Cell Phone

Emergency Contact

Name

Cell Phone

Relationship to Minor

Medical Information

Name of Primary Care Physician/Practice

Phone

Insurance Information

Medical Insurance Company

Policy/Group ID#

Policy Holder's Name

Medication

Please list all medications the minor will take while in our care. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS (exception: rescue inhaler) to the adult leader in their original containers with name of minor and complete dispensing instructions on the container before the start of the event. The adult leader will keep all medical continers locked. Minors are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

List: Medication Name, Dose, Treatment for, Dispensing Instructions

Over-the-Counter Medication Permission: Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Brand-name or generic Tylenol, Advil, antacids, Benadryl) while at a church-sponsored event?

No. Contact me or get medical help if my child has any minor medical concerns. Yes. I give permission for an adult leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions

MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary.

List any medical conditions (asthma, diabetes, epilepsy, etc.):

2. List any allergies (drug/medicine, food, and/or environmental):

3. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.

Parental Consent

The undersigned does hereby give permission for my child (“Participant”), to attend and participate in any Mt. Zion Church children's ministry activitiy (AWANA, KidZone, Vacation Bible School) from the date the form is submitted until May 31, 2024.

LIABILITY RELEASE: I, the undersigned, do hereby release, forever discharge and agree to hold harmless Mt. Zion Church, its pastors, directors, employees, and volunteers (collectively herein the “church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in children's activities. I, the parent or legal guardian, of this minor hereby grant my permission to participate fully in any on-site and off-site children's activity. Furthermore, I, on behalf of my minor, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said church for any liability sustained by said church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency 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 or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned minor pursuant to this authorization.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for said Participant to ride in any vehicle driven by an approved and licensed ADULT leader (25+) while attending and participating in activities sponsored by Mt. Zion Church. My minor and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

Photo Release for Children

By signing this form, I give Mount Zion Church permission to photograph my child and use his or her picture solely for the church’s website (mountzionchurch.org), ministry promotion, or social media accounts. Mount Zion Church will never reveal your child’s name with any of its publications.

Yes No

Comments

Please use the section below for any special details or instructions regarding your child that was not previously listed.

Parent/Guardian Signature

Type your name in the line below, understanding that it represents your signature.

Parent/Guardian Signature

Date

Mt. Zion Child Release & Registration Form 2023-2024

Description

Please Fix the Following