Delburne Gospel Church

HisStory Consent Form

Thank you for dedicating your valuable time to complete this form on behalf of HisStory. We kindly request that this form is solely completed by parents or legal guardians responsible for the child in question. It is important to note that this form requires completion only once throughout the ministry year (September 2023 - 2024).

Name (Required)

Email Address (Required)

Your Phone Number (Required)

Child's Name (Required)

Age Group (Required)

Emergency Contact (Required)

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

Allergies or Medical Info

Birthday

Your 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) ie. Easter Egg Hunt (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)

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 (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 Volunte (Required)

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.

Delburne Gospel Church

2034 27th Ave, Delburne AB