Mission Impossible Perms Is Ion Slip

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Mission Impossible Pemission Slip 2009 Junior High Ministry • South Valley Community Church 8095 Kelton Dr. • 408.848.2363 www.CRASHJH.com

Student Name: ________________________ Phone Number: _________________ Address: ________________________________________ City: _____________ State: ___ Zip: _________ Grade :____________ School: _____________________________ Join our e-mail list? __________________________________@____________________ . _______ Do you have an emergency card on file(You MUST have one on file to come with us)?  fill out back) Payment:

$_________

 Cash

YES  NO (flip over and

 Check #________

While South Valley Community Church makes every effort to provide a safe and pleasant environment for your child, we do require that this participation agreement be read, filled out, signed and dated by the parent or legal guardian of each child under 18 years of age who wishes to participate in the activities which occur with South Valley Community Church. I, the undersigned, give permission for my son or daughter to participate in the activities that occur at Mission Impossible These activities include, but are not limited to, EATING FOOD, TAKING PICUTRES, RIDING IN A BUS, HANGING OUT WITH FRIENDS on the date(s) of March 20, 2009. I grant this permission with full knowledge that I accept full responsibility for any injury or accident that may occur. I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless South Valley Community Church, its officers, Board, agents or employees, for any and all claims for injuries, causes of action, or liability related to my child’s participation in any activity occurring with South Valley Community Church. The release does not apply to intentional and/ or willful acts of misconduct by South Valley Community Church or any of its officers, Board, agents or employees. By signing this document, I acknowledge that if anyone is hurt or property damaged during my child’s participation in this activity, I and/or my child may be found by a court of law to have waived any right to maintain a lawsuit against South Valley Community Church on the basis of any claim which has been released herein. I have had sufficient opportunity to read this entire document. I have read and understood it, and agreed to be bound by its terms.

Parent Name __________________________________

Signature___________________________ Date ___

Junior High Ministry Emergency Card • 2008-2009 South Valley Community Church •8905 Kelton Dr., Gilroy, CA 95020 • 408.848.2363

Please Print Clearly!

Student’s Name ______________________________________________________________

First



 Male

 Female

Last

Address_ _______________________________________ City___________________________ Zip________________ Home Phone #______________________________________ Birth Date______ /_____ /______ Grade in Fall 2008 _ ______ School_ ______________________ Student’s E-Mail Address___________________________________________________ Allergies or Other Concerns?______________________________________________________________________________ Dad’s Name:_______________________________________ Cell/Pager #_________________ Work #________________

First

Last

Mom’s Name:_ _____________________________________ Cell/Pager #_________________ Work #________________

First

Student Lives With:

Last

 Both parents

 Dad

 Mom

 Other:______________________________

AUTHORIZATION OF CONSENT FOR TREATMENT OF A MINOR

(I)(We), the undersigned, parent(s) guardian(s) of do hereby authorize an official of South Valley Community Church to act as designee for the reverse named minor to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is prescribed by, and is to be rendered under the special supervision of, any licensed physician/or surgeon, whether such diagnosis or treatment is rendered at the office of said physician/surgeon or at a hospital or elsewhere. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being rendered and is given to provide authority and power on the part of our aforesaid designee to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician/surgeon may, for reasons he/she deems appropriate, prescribe. (I)(We), hereby authorize any hospital that has provided treatment to the above named minor to surrender physical custody of such minor to (my) (our) named designee(s) upon completion of treatment. This authorization is given for designee(s) for those times that (I) (We) cannot be reached by telephone at home or work at the numbers listed below. This authorization is not to be construed as releasing any physician or surgeon from any requirement that he or she adhere to the lawful standard of care in attending to the named minor and is not to be construed as creating any financial responsibility on the part of South Valley Community Church or the respective directors, officers, employees and agents as well as named officials thereof for any health care provided the named minor. PARENTS ARE RESPONSIBLE FOR PAYMENT. This Authorization to Consent to Treatment of a Minor shall be in full effect for the date range of June 2008 to May 2009.

Parent/Guardian Signature_______________________________________________________ Date___________________ In case of emergency when neither parent can be reached, please notify: Name Address Phone Relationship to Student 1)____________________________ ____________________________ _ _______________ _____________________ 2)____________________________ ____________________________ _ _______________ _____________________

Name of Insurance Company__________________________ Group #_____________ Policy #____________