Minor

Work Entry

Added: 12/21/2024

Minor Medical Hold Harmless Form

Medical Hold Harmless Forms provide insurance and legal information in case of an emergency, and is required for kids, students and adults to participate in certain activities at Fairhaven Church. The Seizures form should be used for any person participating in events that have any medical conditions such as seizures. The form is valid for one year. If something isn't applicable please use N/A.

A copy of this release may be used as if it were an original.

Youth's Information

Youth First Name

Youth Last Name

Do you attend Fairhaven Church weekend services?

If yes, which campus do you attend?

Date of Birth

/ /

Gender

Grade

Address

Parent/Guardian Information

Parent/Guardian's First Name

Parent/Guardian's Last Name

Parent/Guardian's Cell Phone

Parent/Guardian's Email

Additional Parent/Guardian

Parent/Guardian's First Name (2nd)

Parent/Guardian's Last Name (2nd)

Parent/Guardian's Cell Phone (2nd)

Parent/Guardian's Email (2nd)

Emergency Contact (Other than Parent/Guardian)

Emergency Contact Person

Relationship to Child

Emergency Contact: Phone Number

Participant's Health Information

Please list any food, medication or environmental allergies.

Please list any medications (frequency and dosage) being taken by your child.

May we give your child Tylenol or Benadryl as needed?

No Yes

Any additional information about your child's health that is important to know?

Medical Treatment Release Statement

The undersigned parent(s) of child/student named below grant(s) permission to Fairhaven Church, including any of its officers, directors, employees, agents or representatives (collectively, the “Church”) to take any actions it determines are reasonably necessary, including seeking medical treatment, for the purposes of maintaining the child’s health and well-being, in the event of a medical situation or emergency. In such an event, the Church shall endeavor to contact the undersigned parent(s) and emergency contact (if provided) as promptly as possible. By signing this document, I (we) have agreed to the above terms.

Electronic Signature of Parent or Guardian

Clear

Date

Liability Release Statement

The undersigned parent(s) of child/student named below acknowledge and permit child/student to participate in a Children’s/Student Ministry activity (the “Activity”) sponsored by Fairhaven Church (the “Church”). Further, the undersigned parent(s), on behalf of themselves and the Child/Student: (1) release, waive, and forever discharge the Church and any of its officers, directors, employees, agents or representatives (collectively, “Representatives”) from all actions, claims, costs, expenses, liability, or demands arising from or in any way related to the child/student’s participation in the Activity; (2) and shall also agree to indemnify and hold the Church and its Representatives harmless from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees, arising out of the child/student’s involvement in the Activity, and to reimburse the Church or its Representatives, as the case may be, for any such expenses incurred related to the same.

The Undersigned (Parent's/Guardian's Names)

Youth's Name

Electronic Signature of Parent or Guardian Required for Form to be Valid

Clear

Date

Photograph Release Statement

Fairhaven Church has my permission to use my child’s photograph, video and audio recordings, likeness, artwork and/or story in any current or future publications, videos, web pages and any other promotional materials produced, used by and representing Fairhaven Church. I understand the circulation of the materials could be worldwide and that there will be no compensation to me for this use. By signing this document, I have agreed to the above terms.

Electronic Signature

Clear

Date

Submit