I give permission for my son/daughter to participate in youth programs associated with Monadnock Covenant Church for the above dates.

I understand and agree that Monadnock Covenant Church and its agents, volunteers, and employees will take reasonable precautions to provide a safe and healthy environment for my  child(ren).

I am solely responsible for all medical costs associated with any accident or injury involving my child(ren) during weekly youth programs or other church related activity.

I will provide information to Monadnock Covenant Church of my whereabouts. In the event that I am unable to be contacted, I hereby authorize a pastor of the church or a pastor’s designee to consent to emergency medical treatment in the event that my child(ren) is(are) injured or ill. Neither Monadnock Covenant Church nor any of its agents, volunteers, or employees will be held liable on account of my child(ren).

Parent/Guardians’ Signatures Date:___________________________________________________________________________

Child’s Name _______________________________________________________Birth date_____________________________

Address________________________________________________________________________________________________

City, State, Zip___________________________________________________________________________________________

Child’s Email __________________________________________________________________Grade______________________

Known Allergies__________________________________________________________________________________________

Parent/Guardian Names_____________________________________________________________________________________

Home Phone _____________________________Work Phone____________________________

Emergency contact ________________________________________________Emergency Phone_________________________

Parent’s email_____________________________________________________________________________________________

Health Insurance Provider___________________________________________________________________________________

Policy Number _______________________________________Insurance Phone________________________________________