Fun Friday Permission Form Step 1 of 3 33% Student InformationStudent Name* First Last Birth Date* MM slash DD slash YYYY Grade*4567Address Street Address City State / Province / Region ZIP / Postal Code Parent* First Last Cell Phone*Email* Emergency Contact (if parent is unavailable)Name* First Last Phone*Relationship* Confidential Health HistoryHas he or she had (please mark yes or no to each):Allergies?* Yes No Special Needs and / or Medical Conditions* Yes No **Please explain fully if you answered yes to any of the above questions and/or any additional information that would be helpful for leaders to know when ministering to your child? Please check box if you DO NOT give permission for your child's image to be photographed and/or filmed to be used for print, video and/or web publications. CPCKids Health AgreementCPC Leaders reserve the right to require proper use of face mask/face coverings at all events on CPC property (indoor and outdoor). CPC Leaders reserve the right to maintain social distancing standards and direct students towards safe in-person interactions. Our community agrees to act with caution and care for the health and safety of others while respecting all community guidelines to reduce the spread of COVID-19. By signing below, you agree to the following safety guidelines and that your child agrees to follow them. Electronic Signature* Parent / Guardian, please type your first and last name.Permission for medical treatment In the event my son or daughter becomes ill or sustains injury while in the care of or in the supervision of the Centreville Presbyterian Church staff and CPCKids volunteers, they are given permission to administer first aid for my son or daughter’s relief. Consent is also given to admit him or her to any hospital facility and for all medical, surgical, diagnostic, and hospital procedures or treatment as may be performed or prescribed, including the administration of such drugs or medications, by a physician for him or her when such treatment is deemed immediately necessary or advisable to safeguard my son or daughter and it is not advisable or practical to return him or her to me or receive my instruction for his or her care. I waive my right to informed consent for said treatment.Consent* By checking this box and typing my name below, I consent and agree that the child named above can participate in CPCKids Fun Friday.Electronic Signature* Parent / Guardian, please type your first and last name.Date* MM slash DD slash YYYY Δ
