City Chapel

300 West Pioneer Parkway Grand Prairie, TX 75051 Phone: 972-264-6245 Fax: 972-237-0772

2013

Parental Consent Form Liability Release Form

Please Print

Fathers Printed Name: ________________ Signature: ____________________ Cell#: ____________________________________ Mothers Printed Name: ________________ Signature: ____________________ Cell#: ____________________________________ Childrens Home Address: __________________ Apt #: _______ City ________ Zip _________ Home Phone Number: _________ Best E mail:
Child 1

________________________
______ Date of Birth: ______ ____________ ______ ______ Date of Birth: ______ ____________ ______ __ Age: ___ Grade in School: _____

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

Child 2

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

__ Age:

___ Grade in School: _____

We (I) approve City Chapel Inc., Grand Prairie, Texas of using the name, photograph, voice and video of our (my) children) with regards to the ministry. Yes______ No______

MEDICAL INFORMATION
Medical Insurance Co.: _________________________________ Policy Number: ________________________________________ Members Name: _________________________________________ Employer: _______________________________________________
Parental Consent Form To Whom It May Concern: The undersign does hereby give permission for the minor(s) listed in this document to attend and participate in activities sponsored by the City Chapel, Inc., Grand Prairie, Texas during the 2013 calendar year (January 1, 2013 December 31, 2013). We (I) an authorized adult, in whose care the minor(s) has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to the minor(s) under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physical or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the mentioned child(ren) pursuant to this authorization. Should it be necessary for (my) our child(ren) to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission to our (my) child(ren) to ride in any vehicle designated by adult in whose care the minor(s) has been entrusted while attending and participating in activities sponsored by Fellowship of Joy Church, Inc., Grand Prairie, Texas. Liability Release Form In consideration for being accepted by City Chapel, Inc., Grand Prairie, Texas for participation in preschool ministry and/or elementary ministry, and/or preteen ministry, , and/or student ministry, and/or bus ministry and/or Recreational Activities, Camps and Field Trips and any other activities organize by City Chapel Inc., Grand Prairie, Texas including, but not restricted to, swimming, picnics, games, sports, etc., we (I), being 21 year of age or older, do for ourselves (myself) (and for and on behalf of our (my) child(ren)-participant if said child(ren) is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless City Chapel Inc., Grand Prairie, Texas and the director(s) thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whosoever, which may be incurred by the undersigned and the child(ren)-participant that occur while said child(ren) is participating in the above descried trip or activity. Furthermore, we (I) (and on behalf of out (my) child(ren)-participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. (If the participant has not attained the age of 21 years): We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her (them) to participate fully in said trip or activity, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including not limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Furthermore, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation cost.

Witness Signature & Date:

X______________________________________Date________________

Child 3

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

Child 4

______ Date of Birth: ______ ____________ ______ ______ Date of Birth: ______ ____________ ______ ______ Date of Birth: ______ ____________ ______ ______ Date of Birth: ______ ____________ ______

__ Age:

___ Grade in School: _____

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

Child 5

__ Age:

___ Grade in School: _____

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

Child 6

__ Age:

___ Grade in School: _____

Childs Name: Allergies: Disabilities: (ADD, ETC) Medications:

__ Age:

___ Grade in School: _____