Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Parent/Gaurdian Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

First Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Second Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Physician *

First Name

Last Name

Physician Phone Number *

(###)

###

####

I, the undersigned parent/guardian of the minor listed above, do hereby authorize adult workers in charge with Meadowlark Community Church to call 911 in the case of medical emergency for any child and understand that when all attempts to reach 1st and 2nd emergency contacts are unsuccessful, consent to any deemed necessary examination, x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. Further, as parent/guardian of the minors named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services. *

I Agree

In consideration of Meadowlark Community Church permitting my child or myself to participate in Children/Youth Ministry events including approved off campus events, I hereby for my child or myself; heirs, administrators, and assigns, waive any and all rights and claims of any nature I may have against Meadowlark Community Church and any organization connected with any of the events, their representatives, successors, and assigns for any and all injuries or damages of any nature which I may suffer while taking part in any event. I will assume all risks of any kind that may befall on my child or me or any other person as a result of my participation in any event. This waiver and release which includes all claims, demands, costs, losses, damages, attorney's fees and liabilities shall be binding on my heirs, administrators and assigns and run in favor of Meadowlark Community Church. These authorizations shall remain effective upon date of submission, unless revoked in writing and delivered to Meadowlark Community Church. I have read this waiver and liability agreement and understand the terms used and their legal significance. *

I Agree

I also give permission for my child/children and/or myself to be photographed or recorded during MCC events, including Youth Group, VBS, Winter Camp, and other approved off campus events, understand the photos may be displayed in various media formats including website, social media, flyers, brochures, and other similar media for outreach and other ministry purposes for no compensation of any kind. *

I Agree