Kids at the Mill Medical Release Form

Participant's Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Birth *

Date

Parent Phone Number *

Area Code Phone Number

I ( parents name) give (participants name) permission to participate in.. (continued below) *

Parent/Participant name participants name

Children's ministry sponsored in 2020. In case of emergency, I give, Nate Brown, Chandler Davis, or the person placed in charge of my child's permission to have my child treated. I will not hold the individual, the attending physician, or Church at The Mill, Moore, SC or any agent therefore responsible.

Medical Information

Medication currently taking

Food/Medication Allergies

Any allergies

Please check the following medications that you give your permission for your child to take should they be needed:

Tylenol Ibuprofen Mylanta Benadryl Dramamine Vivine Eye Drops Meclizine (Dizziness) Chloroseptic Spray

List any physical, emotional, or mental handicaps so leaders can be sensitive to special needs. This information is confidential.

Insurance Carrier (or NA) *

Policy No. (or NA) *

Emergency Contact Name *

First Name Last Name

Emergency Contact Number *

Area Code Phone Number

I give permission to use pictures, videos, or audio of my child and to be used at the discretion of Church at the Mill in promotional video/audio/publications/website/etc. without notification. *

Yes, I allow. No, I don't allow.

My child and I (or the participant) understand what is expected regarding behavior. Bad behavior will result in forfeiting the privilege of participation in the next trip and being sent home on this trip, at the expense of the parent or guardian. I understand that there are to be no electronic devices (iPods, iPads, gaming devices, etc.) unless permission is expressly given to bring such devices. I also understand that cell phones may be collected on any trip back as we near home. No drugs, alcohol, or weapons of any kind will be allowed.

I, (the parent/guardian/participant) acknowledge that participation in youth activities sometimes necessarily involves risk of physical injury. I further acknowledge that the programs of Church at The Mill Children's Ministry are primarily administered by volunteers and parents who give their time voluntary participation of said individuals in its youth/children's programs, I hereby release, discharge and hold any claims arising out of or relating to any physical injury that may result to said individual while participating in Church at The Mill Children Ministry sponsored activities.

Participant Signature (By signing this, I agree to all of the terms above).

Clear

Parent/Participant Signature (Parent signature is needed for ages younger than 18). By signing this, I agree to all of the terms above. *

Clear

2021 Children Ministry Medical Release Form