Family Fellowship Church of God - Transportation Consent Form

Dependent Information:

First Name

Last Name

Gender

Birthdate

Grade

Allergies

Medications

Primary Care Doctor:

Office Phone Number:

Covered by insurance?

Yes

No

Insurance Provider:

Group Number:

Group Name:

Legal Guardian Information:

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Email

Emergency Contact #1:

First Name

Last Name

Phone Number

Emergency Contact #2:

First Name

Last Name

Phone Number

Transportation Release:

I give permission for my youth to be transported to and from church sponsored activities in a church, rental, or private vehicle.

Initial:

Discipline Release:

In the event of misconduct, I authorize the staff to send my student home at my expense.

Initial:

Insurance Release:

I realize the church insurance begins where the individual health and accident policy terminates. It is only valid when all other insurance has been extended to its limits.

Initial:

Personal Belongings Release:

I realize that the church or its sponsors are not responsible for personal belongings.

Initial:

Guardian Consent:

The undersigned realizes that the participant may incur personal injury or bodily damage while participating in such activities, and acknowledge that the church, it’s officers, directors, employees, agents, or any other parties volunteering on behalf of the church, shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activities of the church. The undersigned further acknowledges this is a full and complete release for all injuries and damages which the participant may sustain as a result of participating in any activity.

First Name

Last Name

Signature

Date Signed:

Transportation Consent Form:

Dependent Information:

Legal Guardian Information:

Emergency Contact #1:

Emergency Contact #2:

Transportation Release:

Discipline Release:

Insurance Release:

Personal Belongings Release:

Guardian Consent:

Service Times

Contact Info

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