Name *

First Name

Last Name

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 *

First Name

Last Name

Parent/Guardian 2

First Name

Last Name

Parent/Guardian 1 Phone *

(###)

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Parent/Guardian 2 Phone

(###)

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Caregiver 1

First Name

Last Name

Caregiver 1 Phone

(###)

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Caregiver 2

First Name

Last Name

Caregiver 2 Phone

(###)

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I consent that any digital photos, video, or audio recordings that I have submitted to the Madison Avenue Presbyterian Church, or that Madison Avenue Presbyterian Church has taken or created of my minor child may be used by Madison Avenue Presbyterian Church, in whichever way it deems appropriate, including print or online media and advertisement, free and clear of any claim whatsoever on my part henceforth. I understand that my child’s name will not be associated with their likeness or identified without prior consent by me. The photo/media will remain the property of MAPC and no compensation will be provided for the use of the photo/media. *

I consent.

I do not consent.

I, as a parent or legal guardian hereby grant permission to the adult supervisors and leaders of the program to make medically necessary decisions with respect to my child, in the event of an accident or injury when parental consent is not available or when circumstances require immediate medical decision, and to administer medication when required. INFORMED CONSENT AND ACKNOWLEDGEMENT I hereby give my approval for my child’s participation in any and all activities at the Madison Avenue Presbyterian Church. I assume all risks and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Madison Avenue Presbyterian Church, its officers, employees, agents and volunteers from any and all liability for accidents and/or injuries to my child during his/her participation in the program. I acknowledge that Madison Avenue Presbyterian Church establishes standards of conduct and supervision of community life to provide for the safety and well-being of all participants in MAPC sponsored events. If a participant chooses to act outside of these standards of conduct, MAPC cannot assume legal responsibility to provide for the safety, care, conduct, or discipline of the child/youth or other participants in connections with such activities regardless of whether these activities are, or are not, officially sponsored by MAPC. I understand that, should the child/youth behave in a manner deemed inappropriate, he/she will be sent home at the undersigned’s expense. *

I consent.

I do not conent.

Name of Parent/Guardian Who Completed Form *

First Name

Last Name