HisStory Consent Form 25/26 | Delburne Gospel Church

Name (Required)

Email Address (Required)

Your Phone Number (Required)

Child's Name (Required)

Age Group (Required)

Birthday (Required)

Name of Person filling out this form: (Required)

Emergency Contact (Required)

In the event of an emergency, who do we contact? Phone number?

Allergies or Medical Info

Family Address

Does your child have any physical, emotional, mental, behavioral concerns or limitations that our staff should be aware of? If yes, please explain.

Is your child bringing any medication with him/her? If yes, please list

I give permission for my child to participate in offsite and onsite events sponsored by Delburne Gospel Church (DGC). (Required)

In the event of medical emergency, I give permission for my child to receive First Aid/medical treatment as determined by Staff or Volunteers, and/or to be transported to the nearest medical facility by Staff or Volunteers or Emergency Services. (Required)

Activities & Transportation (Required)

I recognize that there are risks inherent in activities/transportation that my child may be engaged in, and I will not hold DGC Staff or Volunteers responsible for any personal injury that might occur to my child while participating. If my child commences any action against DGC, its officers, directors, volunteers, agents, servants, or employees, in relation to or arising from my child’s participation in DGC’s ministry activities, I agree to indemnify and save harmless DGC, its officers, directors, volunteers, agents, servants, or employees, from any/all claims and expenses, including legal fees arising from such action, excepting any action arising from or related to any negligent or willful conduct of DGC, its officers, directors, volunteers, agents, servants, or employees.

Photographs or Video (Required)

I understand that photographs or video may be taken of my child during DGC events, and I give permission to use any of these photos/videos for any and all DGC ministry purposes. I release and discharge the photographer/videographer and DGC Staff or Volunteers from any and all claims arising out of use of photos/videos of my child.

I have read, understood and agree with the above and give consent to cover all HisStory activities for the program year effective as stated above. (Required)

Parent/Guardian: I confirm that I am a Custodial Parent or Legal Guardian of the child mentioned above and have legal capacity to approve this release. By choosing "YES", I give consent as a Parent/Guardian of this child.