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GIVE
First Church Coral Springs
Welcome
NEW HERE
What to Expect
New Member
Baptism
CONNECT
Children
Youth (Students)
Small Groups & Bible Studies
Baptism
Serve
Prayer Request
Subscribe to Newsletter
Volunteer Forms
ABOUT US
Who We Are
Our Team
What To Expect
FAQS
Contact Us
GIVE
Annual Parental Consent and Medical Authorization
First Church Student Ministry 2022-2023
Parental Consent & Medical Information
Parents or legal guardian of minors (under age 18) are asked to complete this form and submit.
Date Completed
*
MM
DD
YYYY
Student's Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age
*
Male/Female
*
Male
Female
Mailing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Youth Cell Phone (if applicable)
(###)
###
####
Youth Email (if applicable)
Current School Grade
*
School Attending
I (parent or guardian) give permission for authorized church personnel to send text messages, email, or messages through social media to students pertaining to youth activities.
*
Yes
No
I (parent or guardian) give permission for my child/youth's photograph or video to be used by the church in printed or digital form, including use on the church's website and social media.
*
Yes
No
Does the youth attend First Church worship services on a regular basis?
*
(Minimum of twice (2) a month)
Yes
No
Does the youth's family attend First Church worship services on a regular basis?
Yes
No
Please select the worship service most attended (if any)
8:00am Traditional
9:30am Contemporary
11:00am Traditional
None
Parent 1 or Guardian
*
First Name
Last Name
Relationship to Youth
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Parent's Best Email
*
Parent 2 or Guardian (optional)
First Name
Last Name
Relationship to Youth
Address (if different from above)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
Parent's Best Email
EMERGENCY CONTACT NUMBERS (Additional to parents/guardian):
Name of person to notify in case of emergency if PARENT/GUARDIAN cannot be reached
*
First Name
Last Name
Relationship to Youth
*
Address (if different from above)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Cell Phone
(###)
###
####
Work Phone
(###)
###
####
NAME OF PERSONS AUTHORIZED TO PICK UP STUDENT (if different from above)
Person 1
First Name
Last Name
Best phone number to reach this person
(###)
###
####
Person 2
First Name
Last Name
Best phone number to reach this person
(###)
###
####
CONSENT AND AUTHORIZATION
I, the undersigned being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all scheduled activities for the First Church Student Ministry program to include field trips, swimming, overnight activities, off site, on church grounds, and all activities associated with a church youth ministry. Further, I certify that my youth is physically fit to participate in such events.
First Name
Last Name
Date Signed
MM
DD
YYYY
YOUTH'S MEDICAL INFORMATION/INSURANCE & MEDICAL TREATMENT AUTHORIZATION
Is your youth presently being treated for any injury or medical condition that would limit him/her from youth activities?
*
Yes
No
If yes, please explain:
Is your youth taking any form of medication?
*
Yes
No
If yes, please explain:
(Adult supervisors will not allow any medications unless otherwise noted)
Is your youth allergic to any medications or food?
*
Yes
No
If yes, please explain:
Does your youth require a special diet?
*
Yes
No
If yes, please explain:
Does your youth sleepwalk?
*
Yes
No
Does your youth know how to swim?
*
Yes
No
Youth's Doctor
First Name
Last Name
Doctor's Phone Number
(###)
###
####
Medical Insurance
PLEASE SEND PHOTO COPY FRONT AND BACK OF ID CARD TO LISA@WELOVEFIRST.CHURCH
Policy #
Group #
Plan #
Member #
Phone
(###)
###
####
Fax
(###)
###
####
Primary Insured's Name
First Name
Last Name
Important Medical and Allergy Information
Please check all medications your child is allowed to receive from authorized church personnel/youth staff leadership
Acetaminopnen (Tylenol)
Ibuprofen (Advil, Motrin)
Antihistamines (Benadryl)
Cold Medicine
Antacids (such as Tums)
Anti-Diarrheal (Imodium, etc)
Cough Drops
None Permitted
Medical History
Does your youth have any health conditions such as heart condition, asthma, diabetes, etc. in which we need to be notified?
Yes
No
If yes, please explain the condition and any treatment information:
Please note any medications your youth receives:
I understand that I will be notified in case of a medical emergency involving my youth. However, in the event that I cannot be reached, I authorize medical service and treatment in the event that my youth is injured or becomes ill.
I understand the church and adult supervisors will not be responsible for medical expenses incurred, but that such expense will be my responsibility as parent/guardian.
I agree to notify the church in the event of any health issues that would restrict my youth's participation in any activity.
I also understand that the adult supervisors reserve the right to restrict my youth from any activity that they do not feel is within the physical/mental capabilities of my youth.
Name of Parent/Guardian
*
First Name
Last Name
Date
MM
DD
YYYY
PLEASE READ CAREFULLY. THIS SECTION MUST INCLUDE PARENT/GUARDIAN SIGNATURE.
WE DO NOT REQUIRE NOTARIZED FORMS
EMERGENCY MEDICAL RELEASE - 2020-2021
1. I/we hereby give permission for my/our youth who is a minor, to participate in First Church activities led by authorized leadership. In the event of an emergency or illness, I/we authorize First Church leadership to secure medical treatment for my/our youth.
2. I/we authorize First Church to administer any medication to my/our youth as indicated by a checkmark on the attached form according to the prescribed directions for each. If spaces are left blank, First Church WILL NOT dispense that particular medication unless a physician or parent/guardian is contacted for approval.
3. I/we understand payment for medical bills for my/our youth is my/our responsibility and the student's family insurance plan is responsible for injuries and/or sickness during my youth's participation in Youth Ministry.
4. I/we agree to waive and release First Church, its employees and volunteers from any claim or cause of action that might arise on behalf of my/our youth as a result of his/her participation in this event. Furthermore, I/we assume all responsibility for my/our youth's actions including, but not limited to the cost, repair, or replacement for items damaged by willful abuse of my/our youth to be sent home for medical or disciplinary reasons prior to the conclusion of this event.
By signing below, I (parent/guardian of minor under 18) agree and consent to all above stated.
First Name
Last Name
Date
MM
DD
YYYY
Thank you!
