*Note: This form can be used for up to 1 participant. We only need this permission filled out once a program year (Aug-July). Thanks!
Emergency Contacts and Guardian/Parent Information
(UNDER 18 // participants fill out whole section,
OVER 18 // fill out ER contacts only)
Please bring a photocopy of your medical insurance card and your prescription card (if applicable)
If you have additional info such as any medical or other condition we should be aware of, an activity you wish your child/youth to be excluded from, special needs, dietary restrictions, or who can/cannot pick up your child(ren), please let us know that as well.
UNDER 18 // If the participant is under 18 put the participant's name in the Minor field and the Guardian/Parent's name in the other field.
OVER 18 // If the participant is over 18 put the participant's name in both fields.
I/We, (guardian or parent listed on this form), the parent(s) or legal guardian(s) of (the participant(s) listed on this form) minor (s), and I am informed of the activities offered by Covenant Grove Church located at 4825 Roselle Ave, Modesto, Ca 95357. As the parent or legal guardian of the above-stated student and I give my son/daughter permission to take part and fully participate in all activities, on and off campus, with Covenant Grove Church. I hereby assume all risk of personal injury, sickness, death, damage, and expense as a result in participation in activities. I release, forever discharge, and agree to hold harmless Covenant Grove Church, the directors, staff and volunteers from any and all liability, claims, or demands for personal injury, sickness, or death. I hereby give permission to Covenant Grove Church to take my son/daughter to a doctor or hospital and authorize medical treatment including but not in limitation to emergency surgery, medical treatment, or x-rays. I will assume all responsibility for all medical bills, if any. I and/or my student may be found by a court of law to have waived any right to maintain a claim or lawsuit against Covenant Grove on the basis of any claim which has been released herein. Further, authorization and permission is hereby given to Covenant Grove Church to furnish any necessary transportation, food, and lodging. I grant permission for my son/daughter to be used in any audio, video, and/or photography of activities facilitated by Covenant Grove Church, which may be used for future promotion and/or display. Should it be necessary for my child to return home due to medical reasons, disciplinary action, or otherwise, I hereby assume all costs.
Misconduct may result in transportation home from an activity at parents’ or individual (if over 18) expense. Any participant dismissed for a disciplinary reason will not receive a refund of the activity fee. These rules are to ensure their and other’s safety. Respect one another, staff and adult leaders, No 2-piece swim suits or Guys Speedos, No lighters, fighting, weapons, fireworks, explosives, No students permitted to drive for events, Respect property, Participation with the group expected, No offensive or immodest clothing, No alcohol, drugs, tobacco, sexual relations, Respect and comply with event schedules/rules, obey state, national, and federal laws. Thanks for helping us provide a safe environment.
I consent and agree to the above statements. The information I have disclosed is true to the best of my knowledge. If there are any changes to the above information, I will contact Covenant Grove Church immediately.
By Typing in the name of the Participant and the Parent/Guardian's Name we agree that what was stated here is true, agree to the rules, and give consent to participate in the event.
UNDER 18 // If the participant is under 18 put the participant's name in the Minor field and the Guardian/Parent's name in the other field.
OVER 18 // If the participant is over 18 put the participant's name in both fields.
