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Senior High and Junior High Fellowship at First Church Registration and Indemnification Form

E-mail, cell phone, work phone, snail mail
(ADHD, sports injuries, autism spectrum, history of abuse/neglect, etc.)
With the understanding that pictures might be used in First Church or community publications. Note that First Church does not control the taking of photographs by other participants.

All information is CONFIDENTIAL and for use only by First Church Personnel

Note: No refunds will be issued for any family who has paid any deposit, or in full, and cancels out of any Junior or Senior High Fellowship event or trip .
Today's date
am the parent or guardian having legal custody of
who is, with my permission, enrolled in one or more First Church of Christ, Congregational, Glastonbury ("First Church") church school, youth fellowship or choir programs (the "Programs").

Medical Treatment

I hereby authorize the applicable employee of First Church or any other adult acting as an agent or representative of First Church to take any and all actions that may be necessary or proper to provide for, or arrange for the provision of, the health care of such minor, including, but not limited to, (i) providing over the counter medication and assisting in administering such minor’s prescription medications as needed, (ii) providing for such health care at any hospital or other institution, or employing any physician, dentist, nurse, or other person for such health care, and (iii) consenting to and authorizing any health care, including but not limited to the administration of anesthesia, the taking of X-rays, the performance of tests and operations, and other procedures, by physicians, dentists, nurses, and other medical personnel. I agree to be responsible for any and all charges incurred in connection with any care or treatment rendered pursuant to this authorization, even if an employee, agent or representative of First Church has signed documentation promising to pay for such care or treatment.

Indemnification and Release

On behalf of the minor listed above, I agree to defend, hold harmless, indemnify and release First Church and its officers, trustees, employees, agents, representatives, volunteers, and all others who are involved in the Programs from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from such minor’s participation in the Program. This release includes claims based on the negligence of First Church and its officers, trustees, employees, agents, representatives, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence.

Transportation

I give First Church permission to arrange necessary related transportation for such minor.

Legal signature
*The signer acknowledges that First Church does not guarantee that the preferred hospital will be utilized.
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