Minor Consent Form

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1. Student First Name *

2. Student Last Name *

3. Preferred Name (Nickname)

4. Birthday - Month, Day, Year *

5. Gender * (1 required)

Male Female

6. Student prefers to be contacted by * (1 required)

Email (Must provide email in box below) Phone (Must provide phone number in box below) n/a (this student is 4th grade or younger)

7. Student Email (if applicable)

8. Student Phone (if applicable)

9. School Attending *

10. 2023-2024 Grade *

11. Parent 1 First/Last Name *

12. Parent 1 Cell Phone *

13. Parent 1 Email *

14. Parent 2 First/Last Name (optional)

15. Parent 2 Cell Phone Number (optional)

16. Parent 2 Email (optional)

17. Address *

Address 1
Address 2

City

State

Zip

18. Home Phone

19. Name/Phone of adult or emergency contact who can pick up student *

20. Name/Phone of adult or emergency contact who can pick up student

21. Name/Phone of adult or emergency contact who can pick up student

22. If applicable, list any person(s) who specifically can NOT pick up your student.

23. Student has permission to participate in the following * (1 required)

Nursery Little Lambs Children's Worship Sunday School/Catechism Summer GOkids Cadets GEMS Middle School Ministries High School Ministries

24. Student has permission to be transported in the church van or an authorized vehicle. * (1 required)

Yes No n/a (this student is 2nd grade or younger)

25. Student's Doctor - this is required for participation in FCV's ministries *

26. Student's Doctor's Phone - this is required for participation in FCV's ministries *

27. Medical Insurance Provider - this is required for participation in FCV's ministries *

28. Medical Insurance Policy Number - this is required for participation in FCV's ministries *

29. Student has permission to be in photo/video on church Social Media and promotional materials. * (1 required)

Yes No

30. I give consent for my student to interact with ministry leaders via Social Media and text. * (1 required)

Yes No n/a (this student is 4th grade or younger)

31. Are there any allergies (including food) or health concerns we should be aware of for this student?

By signing Item 32, I am stating that I have read the Code of Conduct PDF below and the Emergency Medical Treatment and Release of Liability statement below.

FCVCRC Code of Conduct Policy PDF

Emergency Medical Treatment and Release of Liability Statement

I recognize that there may be occasions where the participant may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I give permission for all agents (paid staff or volunteers of First Cutlerville Christian Reformed Church to seek and secure any medical attention or treatment for the participant, including hospitalization. If in the agent’s opinion, such a need arises, I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment. I agree to pay all fees and costs involved. I understand I will be notified as quickly as possible. I agree to hold harmless and blameless First Cutlerville Christian Reformed Church and its' agents, and waive all rights to civil action that participant may have or that I may have against them as a result of injury or illness incurred during the course of participation in church activities.

32. E-signature. Parent required to sign in-person at the first event before student participation. *

33. Enter Your Email Address: *

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