Fun Friday Permission FormStep 1 of 250%Student InformationStudent Name* First Last Birthday* Date Format: MM slash DD slash YYYY Grade*456Parent* First Last Phone*Email* Address Street Address City State / Province / Region ZIP / Postal Code 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?*YesNoSpecial Needs and / or Medical Conditions*YesNo**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 allow us to use any photos we take of your child on our website and social media platforms. YesPermission 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* Date Format: MM slash DD slash YYYY
