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Annual consent form 13-14

New Horizons Fel owship C4
Activity Consent Form for
July 1, 2013 – June 30, 2014
(Only one needed per year)

Student Information
Name ___________________________________________________________________________
Address _____________________________________ City/State/Zip ________________________ E-mail ___________________________________________________________________________ Home Phone_____________________ Student Cel Phone_____________________ Accept texts__ Birthday __________________ Grade ____ School _______________________________________ Parent Information
Name ___________________________________________________________________________
Relationship to Student _____________________________________________________________ E-mail _______________________________________ Work Phone _________________________ Home Phone_________________________ Parent Cel Phone _____________________________ Which is best to contact you? Home/ Work/ Cel Do you accept text messages? Yes/ No Medical Information
Special medical needs or concerns (al ergies, conditions, dietary needs, medications, etc.):
_________________________________________________________________________________ ________________________________________________________________________________ Does your child have a history of seizures? Yes/ No Is your child a proficient swimmer? Yes/ No Health insurance information: (please attach a copy of insurance card front and back) Company ________________________________________________________________________ Policy Number ______________________________ Phone Number _________________________ Medical Doctor ______________________________ Phone Number _________________________ Emergency Information
Emergency Contact ________________________________ Relationship _____________________
Contact Phone ______________________________ Alternate Phone ________________________ Over-The-Counter Medication Release
By indicating “Y” beside the listed over-the-counter medications and signing below, I authorize a
representative of New Horizons Fel owship and/or medical professionals to administer said medication in accordance with label instructions if requested by my child. Permission Release
It is my understanding that participating in the programs and recreational and other activities of
New Horizons Fel owship in Apex N.C. is a privilege. Prior to my participation in such activities, I
acknowledge that there are certain risks associated with the activities, including, by way of example,
physical injury due to activity-related accidents, physical injury due to transportation-related
accidents, il ness, or even death. In addition, I acknowledge that there may be other risks inherent in
these activities of which I may not be presently aware.
Release of Liability
By signing this Consent Form, including the Permission Release, I expressly warrant that the child
named above or I (if I am a participant) am capable of withstanding both the physical and mental
demands of the activities discussed above. I also expressly assume al risks of the child or me
participating in the activities, whether such risks are known or unknown to me at this time. I further
release New Horizons Fel owship in Apex N.C. and its agents from any claim that my child may have
or that I may have against them as a result of injury or il ness incurred during the course of
participation in the activities. This release of liability shal include, without limitation, any claims of
negligence or breach of warranty. This release of liability is also intended to cover al claims that
members of the child's or my family or estate, heirs, representatives, or assigns may have against
New Horizons Fel owship in Apex N.C. or its agents. I further agree to indemnify and hold harmless
New Horizons Fel owship in Apex N.C. and its agents from any and al claims arising from my
participation in its activities and programs, or as a result of injury or il ness of my child during such
activities.
First Aid and Emergency Medical Treatment
I recognize that there may be occasions where the child named above, or I, if I am a participant, may
be in need of first aid or emergency medical treatment as a result of an accident, il ness, or other
health condition or injury. I do hereby give permission for agents of New Horizons Fel owship in Apex
N.C. to seek and secure any needed medical attention or treatment for the child name above, or me,
if I am a participant, including hospitalization, if in the agent's opinion such need arises. In so doing, I
agree to pay al fees and costs arising from this action to obtain medical treatment.
I give permission for attending physician(s) and other medical personnel to administer any needed
medical treatment, including surgery and, again, I agree to pay for the medical treatment.
Publicity
On occasion, New Horizons Fel owship takes photographs or makes an audio or videotape recording
of children and/or adults involved in church activities. Such photographs or video records may be
used by staff and participants to remember the activities and participants. In addition, such
photographs and audio/visual recordings may be used in publications or advertising materials of New
Horizons Fel owship in Apex, N.C. to let others know about our ministry. In addition, local news
organizations may hear of our activities or events, and our church may invite or al ow them to
photograph or record our events for news reporting on special interest features. I consent to the use
of any such audio or visual record of the child named above, or me, if I am participating, to be used,
distributed, or displayed as agents of the church see fit.
Photograph Release
In consideration of the benefits of my minor child participating in these activities, I hereby grant New
Horizons Fel owship and its authorized volunteers permission to photograph my minor child during
routine youth group events, as wel as specifical y for the purpose of creating prayer partner
bookmarks and leaders’ prayer books.
Photographs of youth group events taken by New Horizons Fel owship or authorized volunteers
would be posted on premises at New Horizons Fel owship on youth group bul etin boards, or on New
Horizons Fel owship’s social media sites (like but not limited to Facebook, Twitter and Instagram).
Photographs taken of individuals may be used to create a prayer reminder bookmark for the minor
child’s prayer partner to create a prayer book for volunteer leaders, and to publicize past and future
events. Photographs taken and posted by participants and chaperones of the events are not the
responsibility of New Horizons Fel owship.
I authorize this release based on the above-described uses and the fol owing conditions:
1) The photographs taken become the property of New Horizons Fel owship.
2) This release is given with no promise of compensation.
3) This release is effective until terminated by a retraction in writing from the person granting the
authorization.
4) Revocation is only effective to prevent future use of photographs and is not retroactive.
FOR ADULTS (HIGH SCHOOL GRADUATES)
I, ___________________________, have read the above Consent Form and am ful y familiar with
the contents thereof.
I intend to participate in the activities of New Horizons Fel owship in Apex N.C. In consideration for
my participation in the activities of New Horizons Fel owship in Apex N.C., I hereby sign the Consent
Form, including the Permission Release, and agree that this shal be binding upon me, my family,
heirs, legal representatives, successors, and assigns.
______________________________________________
______________________________________________ Printed Name FOR STUDENTS (MINOR OR STILL IN HIGH SCHOOL)

I represent that I am the parent/guardian of ____________________________________. I have read
the above Consent Form and am ful y familiar with the contents thereof.
I give permission for the child named above to participate in the activities of New Horizons Fel owship
in Apex N.C. In consideration for al owing the participation of the child in the activities of New
Horizons Fel owship in Apex N.C., I hereby sign the Consent Form, including the Permission
Release, and agree that this shal be binding upon me, my family, heirs, legal representatives,
successors, and assigns.
______________________________________________
______________________________________________ Printed Name of Parent/Legal Guardian County of _______________________________ I, ________________________________, a Notary Public for said County and State, do hereby certify that ___________________________________ personal y appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this _____ day of ____________________, 20____. My commission expires ________________________

Source: http://www.nhf.cc/wp-content/uploads/2008/03/Annual-Consent-Form-13-14.pdf

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