Changes to information from previous year: *
Please call me to discuss the following:
Medical contact in case of emergency:
Dental contact in case of emergency:
Glasses/Contact lenses/Hearing Aids?
I herby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time. This electronic form serves as my official registration.
And I have legal custody of the child(ren) named and do hereby consent to medical treatment of said child(ren) by any health care provider who said child's(children's) is brought to for medical treatment by, or who is designated by, any minister, employee, agent, or volunteer worker of Newtown Congregational Church, which treatment such medical provider deems necessary or in the best medical interest of said child. I further authorize said minister, employee, and agent, or volunteer to give consent to such treatment and to sign authorization as such medical care provider may require as a condition of treatment. I hereby release the Newtown Congregational Church and its minister, employee, agent, or volunteer from any and all liability, including liability from negligence, on account of said minister’s, employee’s, agent’s, or volunteer’s actions or non-action in obtaining medical treatment for said child, and release any such provider from any and all liability on account of any claim that such treatment was not consented to by me. I acknowledge that I will ultimately be responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance carrier. I agree to bring my child home at my expense should he/she become ill or if deemed necessary by chaperone(s) or minister, employee, agent, or volunteer of Newtown Congregational Church.
I have legal custody of the child(ren) named and do hereby give my consent for him/her/them to attend events organized by Newtown Congregational Church. I acknowledge that some of the events have inherit risks of injury which I assume on behalf of said child(ren). Additionally, I hereby release Newtown Congregational Church, its ministers, employees, agents, or volunteers of any and all liability, in the event an injury to said child(ren) or their property which might occur during or as a result of the child’s (children's) participation in such events and agree to hold Newtown Congregational Church and its ministers, employees, agents, or volunteers harmless from any claims against them arising out of said child’s participation in events organized by the church.