Youth/Child Indemnification, Release and Medical Consent Form

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The First Church of Christ, Congregational, Glastonbury

This form is used for church school, youth fellowship and choir programs.

This form must be filled out for all minor children participating in all church activities where parents/guardians are not present, including choir rehearsals, fellowship sessions and any off-site or overnight activities organized by First Church.

I, *

am the parent or guardian having legal custody of

Child's Name *

a minor,

Age, born on *

Date of birth

is, with my permission, enrolled in one or more First Church of Christ, Congregational, Glastonbury (“First
Church”) educational, missional, choral, or fellowship 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.

Photographs *

Yes

give permission for such minor’s photo to be taken by Church staff or volunteers during activities of the Program, 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.

Check boxes *

Yes

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

Physician's Name & Phone *

Preferred Hospital *

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

Insurance Carrier & Group #/ID *

Name of Insured *

Signature *

I have read the above form and by checking the box, sign and indicate my agreement with its terms. I agree that checking the box will be the electronic representation of my signature for all purposes on this document just the same as a pen and paper signature.

Legal signature

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Youth/Child Indemnification, Release and Medical Consent Form

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FIRST CHURCH OF CHRIST CONGREGATIONAL
Glastonbury, Connecticut

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Search form

Youth/Child Indemnification, Release and Medical Consent Form

Primary tabs

FIRST CHURCH OF CHRIST CONGREGATIONALGlastonbury, Connecticut

FIRST CHURCH OF CHRIST CONGREGATIONAL
Glastonbury, Connecticut