The Pentecostals of The Woodlands - Children's Consent Form

General Contact Information

Child's First Name

Child's Last Name

Parent or Guardian's First Name

Parent or Guardian's Last Name

Mobile Number

Emergency Phone Number

Parent or Guardian's Address

Address 1

Address 2

Country

City

State

Zip/Postal Code

Medical Information

Is your child presently being treated for an injury or sickness or taking any medication?
Yes
No

If your child is being treated for an injury or sickness or taking any medication, please explain. If this is not applicable, put the response "N/A".

Does your child have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?
Yes
No

If your child has a physical handicap or illness that would prevent him or her from participating in normal rigorous activity, please explain. If this is not applicable, put the response "N/A".

Does your child have allergies? If so, please list them below.

Consent and Certification

I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in children’s activities conducted by The Pentecostals of The Woodlands. I certify that my child is physically fit and adequately prepared to participate in this event.

Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my child is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my child, if required by law or a health care provider:

Church Representative's First Name

Church Representative's Last Name

or another adult chaperone designated by the pastor. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that The Pentecostals of The Woodlands will not be responsible for medical expenses incurred solely on the basis of this authorization. I also understand that the designated adult chaperones reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.

I consent to the participation of my child in children’s activities conducted by The Pentecostals of The Woodlands. I certify that my child is physically fit and adequately prepared to participate in this event.
Yes
No

Please type your full name below as a declaration of consent.

Children's Activity Consent Form

Children's Activity Consent Form

General Contact Information

Parent or Guardian's Address

Medical Information

Consent and Certification

Medical Treatment Authorization

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