Registration for CCF

2017-2018

Registration for CCF

Parent/Guardian Permission and Liability Waiver
Grade 6 7 8 9 10 11 12 Circle
Date(s): From this day___/_____/______until 08/15
Type of Event: All CCF Youth Group Events on or off CCF property

Student’s Name: ______
Birth Date: ______Age: ______Grade: ______Gender: MF
Parent/Guardian’s Names (s)______Relation to student: ______
Full Address: ______
Home Phone: ( )______Business Phone: ()______
Cell Phone: ( ) ______Text Youth Group Reminders/ Updates to this # : ___ Yes ___ No
Student Phone: ( )______Text Youth Group Reminders/ Updates to this # : ___ Yes ___ No
Parent Email Address: ______

Student Email Address:______

Code of Conduct at all CCF Youth Events:

Respect staff, adult leaders and one another
Participation with the group is expected
Respect all property
No immodest or offensive clothing
No possession or use of alcohol, drugs or tobacco
No fighting, weapons, fireworks or lighters

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct and agree to abide by them.

Student signature: ______Date: ______

Permission to Participate:
I,______, grant permission for my son/daughter, ______
Parent or Guardian’s Name Child’s Name
to participate in all CCF youth ministry events, including those that require transportation to a location away from the church site. I will agree to these off-site events by signing the individual permission slips. These activities will take place under the guidance and direction of employees and/or volunteers from Community Christian Fellowship Church.
Hold Harmless Agreement:
As parent/legal guardian, I remain legally responsible for any personal actions taken by my son/daughter named above.I agree on behalf of myself, my son/daughter named herein, our heirs, successors, and assigns to hold harmless and defend Community Christian Fellowship Church, its Pastors, officers, directors and agents from any liability for illness, injury or death arising from or in connection with my son’s/daughter’s attending the above named event, and I agree to compensate Community Christian Fellowship Churchits Pastors, officers, directors and agents or representatives associated with the event for reasonable attorney’s fees and expenses arising in connection therewith.
Signature of Parent/Guardian:______Date:______
Signature of Parent/Guardian:______Date:______

MEDICAL CONSENT AND PERMISSION TO TREAT

To the best of my knowledge, my/our child, ______is in good health, and I/we assume all responsibility for the health of my/our child. In the event of an emergency, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician and to transport my/our child to a hospital for emergency treatment. I/we agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member. Further, I/we affirm that the health insurance information provided below is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named.
Signature of Parent/Guardian:______Date:______
Please include a copy of your insurance card, front and back.
Insurance Carrier:______Policy Number:______
Emergency Contact Information:
Parent/Guardian’s Name: ______
Full Address: ______
Home Phone: ( ) ______Business Phone ( )______
If you are unable to reach me, please contact:
Name: ______
Relationship to me or my son/daughter:______

Medical History:

Student name: ______
-My son/daughter is under the care of a psychiatric/psychologist. ______Yes ______No
Name: ______Phone Number: ( )______
Please explain: ______
-My son/daughter is taking medication and will bring all medication with him/her and it will be clearly labeled.
My son/daughter is taking the following medication(s) and directions for taking this medication, including
dosage, frequency and storage are as follows:______
______
-I hereby grant permission for non-prescription medication (such as cough drops, cough syrup, Tylenol, etc.) To be given to my child if necessary. ______Yes ______No
-My son/daughter is allergic to the following:______
-My son/daughter’s immunizations are current and up to date ______Yes ______No
-My son/daughter has the following limitations:______
-My son/daughter experiences homesickness, emotional reactions to new situations, sleepwalking, fainting or ………..
Please explain:______
Signature of Parent/Guardian:______Date:______