Due to the weather: Friday, offices closed. Saturday work day postponed.
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WAKE CONSENT FORM
WAKE Parental Permission & Medical Consent
Student's Name
2nd Student's Name
3rd Student's Name
Address 1
Address 2
Country
City
State
Zip/Postal Code
Emergency Contact Name
Emergency Contact Number
Student's Birthday
2nd Student's Birthday
3rd Student's Birthday
The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the "Child"), hereby consents to the participation by the Child in WAKE Student Ministries Events from September 1 2020-August 31 2021 conducted by Thousand Hills Church and to the participation of the Child in all activities relating to WAKE Student Ministries from September 1 2020-August 31 2021. All activities would include, but not be limited to: inflatables, basketball, gaga ball, foosball, and ping-pong, outdoor gaming (including, but not limited to football and volleyball,) water wars, color wars, laser tag, retreats, Youth Convention, District Fine Arts Festival, National Fine Arts Festival, Lakeview Youth Camp, Main Event. I understand that my child at times might be riding in a vehicle owned/operated by Thousand Hills Church or WAKE Adult Leaders for these activities.
Yes
No
The undersigned hereby further authorize(s) any of the staff, employees, agents and representatives of Thousand Hills Church to provide for, approve and authorize any health care at any hospital, emergency room, doctor’s office or other institution; employ any physicians, dentists, nurses, or other person whose services may be needed for such health care; review and if necessary disclose the contents of any medical records; execute any consent form required by medical, dental or other health authorities incident to the provision of medical, surgical or dental care to the child. Health care shall include but not be limited to the administration of anesthesia, X-ray examination, performance of operations, diagnostic and other procedures. If there is no medical emergency, the guardian will first use reasonable efforts to contact the parent(s) and/or guardian(s) before administering or authorizing any treatment. Notwithstanding other provisions in this Consent Form, Thousand Hills Church shall not have the authority to withhold or withdraw life-sustaining procedures for the Child. Students will only be released to guardians, or those designated by their guardians.
Yes
No
I give consent for photographs in which my child(ren) may appear to be used for publications in print, electronic media, social media, and the internet and for public relations activities of Thousand Hills Church.
Yes
No
Gaurdian's Full name
Date
Signature
Submit
