WHC Parental Consent and Liability Statement

Activity Child is Attending: *

Choose which activity your child will be attending.

Child's Name: *

First

Last

Child's allergies or medical conditions:

Please list any allergies or medical conditions we need to be aware of, particularly in a medical emergency.

Health Insurance Company *

Please write None if the child doesn’t have medical insurance.

Policy or Group # *

Please write None if the child doesn’t have medical insurance.

Doctor's Name:

First

Last

Doctor's Phone:

I have read and understood: *

I certify that my child is physically well. I certify that no health-related reasons or problems preclude my child’s participation in the trip mention above.

Please check.

I have read and understood: *

I understand that the risks associated with camp activities could result in injury to my child. I hereby assume these risks and, knowing them, hereby give my child permission to participate. As a part of this activity, I understand it will be necessary for the participant to engage in travel. I hereby grant my permission for such travel. I understand that the World Harvest Church is not liable for any injuries or other occurrences due to indoor and outdoor camp activities or related risks, or the actions or omissions of WHC counselors, volunteers, employees, or any other entities being released.

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I have read and understood: *

In the case of an emergency affecting the health or welfare of my child named above, the counselors, leaders, or adult chaperones have permission to administer first aid and or transport my child to the nearest doctor or hospital for further emergency medical attention as deemed necessary. The individual acting in response to the emergency, World Harvest Church, and its representatives will be held blameless.

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I have read and understood: *

I hereby grant permission for my child to receive emergency medical treatment, to be hospitalized, and to receive such injections, anesthesia, or operation as may be urgently necessary.

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I have read and understood: *

In an emergency, I understand that I will be notified of the situation as soon as practicable. I agree to pay any necessary expenses incurred in my child’s medical treatment, including, but not limited to, all transportation costs to and from a medical facility and, if necessary, transportation to my home or medical facility of choice.

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I certify that: *

I’m the parent or legal guardian of the child listed above. I certify that I have read this document, fully understand its content, and agree to its terms.

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Parent's Name: *

First

Last

Parent's Email: *

Parent's Phone: *

Date *

Parents's Signature: *