St Paul Preschool Registration Consent

Child Information:
 
Date of Birth:
Goes By:

Family Information:
Mother's Information


Email:
Home Phone:
Cell Phone:
Work Phone:

Father's Information


Email:
Home Phone:
Cell Phone:
Work Phone:

Emergency Contact Information:
First Emergency Contact

Cell Phone:  
Relationship to Child:   

Second Emergency Contact

Cell Phone:  
Relationship to Child:  

Persons Authorized to Pick Up My Child:
1. 
2.
3.  

Emergency and Medical Information:
Physician's Name:  
Physician's Phone:  
Preferred Hospital:  

Insurance Company:  
Policy Number:  
Group Number:  

Emergency Consent and Release:

Preschool Release and Consent to Medical Care
I hereby give me permission that my child, , may be given emergency treatment by St. Paul Preschool.  I also give permission for my child, , to be transported by car or ambulance to an emergency center for treatment.  In the event that I cannot be contacted immediately, medical or surgical treatment can be administered to my child, , in the case of an accident or emergency, as prescribed by a treating physician.

St Paul Church of Columbus Release to Participate and Medical Care
I give permission for   to participate in this St. Paul Church of Columbus sponsored event.  I understand that all youth and children's events may involve certain risks of physical activity and that there is a risk of injury associated with the activities.  

Nonetheless I wish to have my child, , participate in this activity or program and ASSUME THE RISK of participating.  I agree to WAIVE, RELEASE from LIABILITY, INDEMNIFY, HOLD HARMLESS AND COVENANT NOT TO SUE St. Paul Church of Columbus, and their officers, employees, volunteers and agents (hereinafter the RELEASEES) from any and all claims and/or causes of action arising out of and related to any injury, loss, penalties, damage, settlement, costs or other expenses or liabilities that occur as a result of my child's participation in this St. Paul Church of Columbus sponsored event, including claims arising out of the negligence of the above-mentioned RELEASEES.

I (we) the parent(s) or legal guardian(s) of , do hereby grant permission for our child to participate fully in the activities, specifically the St Paul Preschool, and all of its activities and hereby give permission to take said participants to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery and I (we) fully and completely assume all responsibility for all medical bills.  I (we) the parent(s) or legal guardian(s) of the participant does hereby grant permission for our child to participate fully in the St Paul Preschool.  I/We assume all risks and hazards incidental to the conduct of the activities.  We do further hereby waive, release, absolve, indemnify and hold harmless, St. Paul Church of Columbus and any of their respective affiliates, successors, agents, employees, members, representatives, adult sponsors, and other volunteers involved in the activities, and transportation and associated with the event from any and all claims, including claims of personal injuries to my/our child/youth or property damage, and specifically including those claims resulting from the negligence of St. Paul Church of Columbus and any of their respective affiliates, successors, agents, employees, members, representatives, adult sponsors, and other volunteers.  If I cannot be reached, I authorize the authorities of the program to make whatever arrangements the circumstances allow.

I (we) the parent(s) or legal guardian(s) of the participant do hereby understand that any participant with high fever, other signs of infections or with uncontrollable behavior problems will be returned to the home.

I agree that my child, , will abide by the rules as set forth by the program staff, chaperones, and faculty of St. Paul Church of Columbus, as well as any additional rules made by program staff, chaperones, and chaperones associated with St. Paul Church of Columbus.