Pleasant Hill Christian Church Release Form

Pleasant Hill Christian Church is striving to maintain a high level of security for your

child(ren) regarding promotional materials and website development.

The following is a request for your permission to use your child’s photo and/or first name. Please complete the appropriate blanks, sign and return to the church.

Child’s Name______

NAME RELEASE:

______Yes, I give permission for my child’s first name ONLY to be featured in slideshows, bulletin boards, newsletters, church displays, and on the World Wide Web.

______No, I do not give permission for my child’s first name to be featured in slideshows, bulletin boards, newsletters, church displays, or on the World Wide Web.

PHOTO RELEASE:

______Yes, I give permission for my child’s photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, and church displays.

______No, I do not give permission for my child’s photo or other illustrating materials to be featured in slideshows, bulletin boards, newsletters, or church displays.

WORLD WIDE WEB:

______Yes, I give permission for my child’s photo or other illustrating materials to be featured on the World Wide Web.

______No, I do not give permission for my child’s photo or other illustrating materials to be featured on the World Wide Web.

Parent/Guardian Signature Date

______

Participant Information

Participant Name______

Address ______

City ______State ______Zip ______

Home Phone ______Cell Phone ______

Health Insurance Information

Health Insurance Company______

Policy Number ______

Known Allergies and Reactions ______

Medications Currently Taking ______

Parent/ Guardian & Emergency Information

Name (with whom you live) ______

Emergency Cell Phone # ______

Parent(s) email ______

Person to notify if parent/legal guardian cannot be reached:

Name______Phone # ______

Relationship ______

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  • I, the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in the activities of Pleasant Hill Christian Church. Valid from May 2017 until May 2018.
  • The individual identified on this form understands that all participants are expected to abide by the rules of the adult sponsors in charge of this activity.If necessary, a participant may be required to leave due to misconduct or disobedience. I will assume full responsibility for returning the participant home.
  • Further, I do authorize the minister or sponsor of this activity, in the event I cannot be reached by phone, to give consent to a physician and/or hospital for emergency medical or surgical treatment while on this trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for said emergency treatment.
  • I release Pleasant Hill, its staff and sponsors from liability in the event of an accident.
  • I have read and agree to the information given in this entire form.
  • My consent and signature is given below.

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Name of Participant ______

Printed Name of Parent/Legal Guardian ______

Signature of the Parent/Legal Guardian ______

Date ______

RELEASE FORM- Pleasant Hill Christian Church