2017-18 Pine Valley NextGen Activity Permission, Release and Medical Power of Attorney


1. I, the lawful parent or guardian of (the “child”), give permission for my child to participate in all activities and events hosted, attended or organized by Pine Valley NextGen youth ministry for the school year of 2017 and 2018 (starting September 2017 and going through the end of August 2018) and release from all liability and indemnify the International Church of the Foursquare Gospel d/b/a Pine Valley Church and its directors, officers, council, agents, representatives, volunteers, and employees (“Church”) from any and all liability, claims, judgments, cost or expenses, including attorney fees, arising out of any damage, injury or illness incurred or caused by my child while participating in or traveling to or from said activities/events, or otherwise in Church custody. I understand the risks in these activities, including the possibility of unforeseen hazards, serious injury or death. I certify my child is able to participate in the activity.

2. I agree to instruct my child to cooperate with the Church and its representatives in charge of the activities/events and understand my child may be prohibited from participating and/or sent home for any failure to follow the rules established by the Church.

3. I appoint Church representatives who are acting as leaders, or designated by such leaders, as my attorney in fact to act for me in my name and my behalf, in any way that I could act if I were personally present, with respect to the following matters if any injury, illness or medical emergency occurs during the activity, related travel or while my child is in Church custody.

a. To give any and all consents and authorizations to any physician, dentist, hospital or other persons or institutions pertaining to any emergency transportation, medications, medical or dental treatments, diagnostic or surgical procedures or any other emergency actions as our medical attorney-in-fact shall deem necessary or appropriate for the best interest of the child.

b. I understand the Church will make a reasonable attempt to contact me as soon as possible in the event of a medical emergency involving my child.

4. My child is to be excluded from the following activities and/or from release to the following persons (IF LEFT BLANK, NO ACTIVITIES OR PERSONS ARE EXCLUDED.)

5. I agree that the Church may use my child’s and/or my own name, voice, portrait, photograph or image for promotional, website, office or any other church related purposes. These may be used in any broadcast, telecast, digital or print medium, including video images, photographs, pictures or renderings, audio recordings, or other likenesses, in combination or alone.

I will notify the Church immediately of any change in the information presented and agree it is valid until revoked in writing by me. I have carefully read this statement, and my signature acknowledges that I fully understand the content and meaning.

Medical Information — Completed by Parent or Guardian

Child’s Name:
Birth Date:
Allergies:
Medications:
Chronic/other medical conditions (e.g. epilepsy, diabetes, asthma, heart, etc.):
Child’s Cell (if applicable):
Child’s Email (if applicable):

Medical Insurance Company:
Policy number:
Family Doctor:

Parent/Guardian Name:
Parent/Guardian’s Phone:
Parent/Guardian’s Email:
2nd Parent/Guardian Name:

Emergency Contact and their relation to child:
Emergency Contact Phone Number:

Leave this empty:

Pine Valley Church http://pinevalleychurch.org
Signature Certificate
Document name: 2017-18 Pine Valley NextGen Activity Permission, Release and Medical Power of Attorney
Unique Document ID: d761dea392eb77ad2c4a9f8f87997ffe4245a5b8
Timestamp Audit
2017-08-09 13:07:25 MST2017-18 Pine Valley NextGen Activity Permission, Release and Medical Power of Attorney Uploaded by Carrie Van Hoesen - carrie@pinevalleynextgen.com IP 71.218.232.103