Child's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Gender *

Male

Female

Are there any known medical conditions/concerns?

Yes

No

Are there any medications you will be sending with your child?

Ex. Epi-pens, inhalers.

Yes

No

Are there any known allergies?

Yes

No

Mother's Name *

First Name

Last Name

Mother's Phone *

(###)

###

####

Is it okay to text?

Yes

No

Mother's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Father's Name

First Name

Last Name

Father's Phone

(###)

###

####

Is it okay to text?

Yes

No

Father's Address

Only add if different than mother's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

This must be someone different than a parent

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Checkbox(I), (We) the undersigned parent(s) of the child mentioned above, a minor, do hereby authorize Westminster Presbyterian Church’s children’s ministry leaders as agents for the undersigned to consent to any x-ray examination, anesthetic, medical or surgery diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician and surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agents to give specific consent to any and all such diagnosis treatment or hospital care which the aforementioned physician in the exercise of his best judgment may deem advisable. This authorization is given pursuant to the provisions of Section 25:8 of the Civil Code of California. This authorization is for all children’s ministry activities at Westminster Presbyterian Church.

By clicking the box below you are agreeing that the check box is the same as a digital signature.

Yes, we agree to the statement above.

No, we do no agree to the statement above.

(I), (We) the undersigned parent(s) of the 'child listed above', a minor, do hereby authorize Westminster Presbyterian Church’s children’s ministry leaders to photograph and video tape our child in an appropriate and tasteful manner. We realize that pictures may be used in slide shows, newsletters, the church web-site, and other church related uses. Video may also be used for publicity, activities, and other program related uses.

Yes, I agree.

No, I do not agree. Please withhold any photos/video of my child/children.

We, the parents of the ‘above mentioned child,’ shall indemnify, hold free and harmless, assume liability for, and defend Westminster Presbyterian Church and it’s affiliate corporations , its agents, servants, employees, officers, and directors from any costs and expenses including but not limited to, attorney’s fees, reasonable investigative and discovery costs, court costs, and all other sums which the Westminster Presbyterian Church may incur based on any assertion of liability, or any other claim or action founded thereon, arising or alleged to have arisen out of ‘the above mentioned child’ use of real or personal property belonging to Westminster Presbyterian Church and its affiliate corporations, its agents, employees, officers, and directors, or by action or omission by ‘the above mentioned child.’ *

By clicking the box below you are agreeing that the check box is the same as a digital signature.

Yes, I agree