Montrose Church Parental Consent 2025-26 (Long)

To be completed by parent or legal guardian.

Your name *

Email address *

Phone number *

Parent/Guardian Address *

Parent/Guardian Relation *

Child Information

In the event that medical intervention is needed on behalf of my child, named below, I understand that every attempt will be made to reach their emergency contact. In the event I/they cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, x-ray, or surgery for my child as deemed necessary from January 1, 2025 through July 31, 2026.

Child's Name *

Please enter the child's full name.

Child's Date of Birth *

Insurance & Physician Information

Medical Insurance Carrier *

Policy #: *

Physician: *

Physician Phone: *

Please enter in the format 999-999-9999.

Dentist: *

Dentist Phone: *

Please enter in the format 999-999-9999.

Emergency Contact Information

Emergency Contact (1) *

Please enter the Emergency Contact's full name.

Emergency Relation (1) *

Please enter the relationship to the child: parent, guardian, aunt, sister, etc.

Emergency Phone (1) *

Please enter in the format 999-999-9999.

Emergency Contact (2) *

Please enter the Emergency Contact's full name.

Emergency Relation (2) *

Please enter the relationship to the child: parent, guardian, aunt, sister, etc.

Emergency Phone (2) *

Please enter in the format 999-999-9999.

Medical History

If necessary, describe in detail the nature and severity of any physical and or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which the participant is subject, and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing and attach to this form. Include names of medications, and dosages that must be taken.

Please list any allergies

Date of last Tetanus shot *

Are all immunizations up to date? *

Yes

Please list any dietary or activity restrictions

Please list all medications

Include name of medication, purpose, dosage, and whether assistance to administer is required.

Please list any major illnesses or injuries within the last year

Additional comments

Please include any accommodations or special needs.

Additional information

Please attach files containing any additional information

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Add up to 5 files. Maximum file size 10 MB.

Code of Conduct

Participants agree to conform to these rules of conduct:
• No possession or use of alcohol, drugs or tobacco
• No participants can drive
• No fighting, weapons, fireworks, lighters, or explosives
• No offensive or immodest clothing
• No males in female sleeping quarters and no females in male sleeping quarters
• Participation in the group is expected
• Respect property
• Respect one another, staff and adult leaders
• Respect and comply with event schedules

Initial Here *

Participants who fail to comply with these expectations may be sent home at the expense of the parent/guardian. Type your Initials here to acknowledge.

Acknowledgments and Consent

Parental Acknowledgment *

I, the parent/, have read the rules of conduct, the above evaluation of health, and reviewed it with the my child. I hereby request permission for my child to participate in Montrose Church group activities. I agree that my child will abide by the stated personal limitations and code of conduct.

Program Acknowledgment *

Activities may include, but are not limited to: cookouts, boating, water-skiing swimming, basketball, roller-blading, roller-skating, games in the park, soccer, broom ball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, rock climbing, surfing, boogie boarding, drama, choir, community service projects, retreats, conferences and seminars. I understand that my child’s photo or video may be taken at church activities and I authorize Montrose Church to post this media on the church website or use them in other church materials. NOTE: If you wish to limit the participation in any event, please submit your wishes in writing to Program Pastor prior to the event.

My child has permission to attend all activities sponsored by Montrose Church (hereinafter the "Church") for the period above on this form.

Digital Consent & Signature

This consent form gives permission to seek whatever medical attention is deemed necessary, and release the Church and its staff of any liability against personal losses of named child. I the undersigned have legal custody of the student named above, a minor, and have given my consent for him/her to attend events being organized by the Church. I understand that there are inherent risks involved in any ministry or athletic event, and I hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my child’s involvement in the event that he/she is injured and requires the attention of a doctor. I consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and or hospital personnel designated by the church, I agree to hold such persons free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still in force for the minor named above. I also agree to bring my child home at my expense should they become ill or if deemed necessary by the pastoral staff member. I also have read, understand, and agree to everything stated above and hereby certify that, to the best of my knowledge, the information provide is true and accurate.

Consent *

Yes! I certify that I am the parent/legal guardian of the child(ren) named above and am authorized to provide consent on their behalf.

Digital Signature *

My typed name below serves as my digital signature.

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