5th-6th Grade Gathering Photo/Medical Release Form

Child's First and Last Name

Child's Date of Birth

Parent First and Last Name

This address will receive a confirmation email

Photo Release

Photos taken by volunteers may be used for internal presentations at Redeemer only.

Do we have permission to use your child’s photo for internal Redeemer purposes?

Yes No

Do we have permission to use your child’s photo for the Redeemer website?

Yes No

E-signing Disclosure

Be e-signing below, you acknowledge and give Redeemer the right (or not) to take and use photos of your child for internal Redeemer purposes and/or the Redeemer website.

Parent or Guardian Signature

Today's Date

Medical Release

Does your child have any food allergies or other allergies?

Yes No

If yes, please list the allergies:

Does your child have other medical/physical conditions or limitations of which we should be aware? (such as asthma, diabetes, dietary constraints in addition to allergies, etc.)

Other information you feel might be helpful for us to know concerning your child (learning disabilities, developmental issues, etc.):

E-signing Disclosure

In case of injury & if I am unable to be contacted after a reasonable attempt has been made, the staff/volunteer representative of Redeemer Presbyterian Church is hereby authorized to act on my behalf should my child need medical attention.

In consideration of the benefits to be derived from these activities and acknowledging by e-signing below, I release, discharge and hold harmless Redeemer Presbyterian Church, its employees, representatives or those supervising events from any and all claims arising from my child’s participation in these activities, or as a result of injury or illness of my child occurring during an activity. I understand that adequate and appropriate precaution will be taken for the safety and supervision of my child at all times.

Parent or Guardian Signature

Today's Date

Description

Please complete additional form for each child who attends this event.

5th-6th Grade Gathering Photo/Medical Release Form

Description

Please Fix the Following