THIS FORM WILL REMAIN ACTIVE FOR ONE YEAR FROM THE DATE OF THE SIGNATURE UNLESS REVOKED BY PARENT OR LEGAL GUARDIAN.
PARENT / GUARDIAN INFORMATION
PERSON(S) AUTHORIZED TO PICK-UP YOUR CHILD
Please note that your child will not be allowed to leave with anyone that is not on this list.
INSURANCE & EMERGENCY CONTACT INFORMATION
An emergency contact must be an individual other than a parent or guardian. This person would be contacted in case of an emergency when the parents or guardians cannot be reached.
if you do not have health insurance, please enter N/A
At HCFKNOX, we like to use photos from church events to share with church members and for promotional use. Any photos on HCFKNOX's social media pages and website do not include children's names or addresses.
By checking below, I do or do not give my full consent to HCFKNOX to photograph, video record, or audio record my child in the participation of HCFKNOX programs or associated events. Furthermore, I hereby transfer and assign to HCFKNOX the exlusive right to use my child's photograph(s), audio recording(s), or video recording(s) in church promotional materials. I understand that the photographs, audio recordings, or video recordings may be used in a publication, electronic media, or other form of church promotion. I understand that my child's name and address will NOT be published in any form without additional, separate consent.
I (Parent/Guardian) do hereby give my permission for my child to receive emergency medical care. In addition, I will not hold HCFKNOX or any employee or representative therof, responsible for any expense, claims, or liability arising from an injury to my child.
Any child under the age of 18 must be given permission by the parent or legal guardian to be transported by church staff or volunteers to any event. Please note that the church van, rental vehicles, and personal vehicles all may be used for the transportation of groups.
If at any time you wish to revoke this permission, you must submit it in writing and turn it in to the church office.
I hereby give my permission for my child listed above to ride the van or other vehicles used for church functions. I understand that my child will be under adult supervision. I further understand that by signing this form, I release and hold harmless HCFKNOX and all employees, staff, members, board members, officers and any volunteer from any liability, past or furture, fully and completely. I authorize the staff or designated medical professionals and/or volunteers to administer emergency medical assistance if I cannot be reached.