Annual Children & Student Ministry Emergency, Medical, and Permission Form

Please fill out a separate form ANNUALLY per child in your household for insurance and policy purposes.

Your name *

Email address *

Child's Name *

First, Middle, and Last

Address *

Phone number *

Please list all parent/guardian names for emergency contact purposes.

Please list all parent/guardian phone numbers for emergency contact purposes.

Date of Birth of Child *

School Child Is Currently Attending *

Grade *

List all people who are allowed to pickup your child *

Any chronic physical problems, developmental concerns, or special accommodations needed for your child? *

Any allergies or intolerances? *

Insurance Carrier *

Please list your insurance carrier. If child does not have insurance, type "none."

Insurance ID

Name of Policy Holder

Relationship to Policy Holder

Is child taking any medications *

Child's Physician Name, Address, and Phone Number *

List child's physician name, address, and phone number

Child's Dentist Name, Address, and Phone Number *

List child's dentist name, address, and phone number

Medical Permissions *

I give my consent for any staff member to contact the above named physician and dentist if my child has an emergency. I understand that if my child's physician or dentist is not available, another physician or dentist may be contacted on an emergency basis. I also give my consent for the staff to seek medical attention in an emergency. I give permission for my child to be transported by ambulance. I will be responsible for all medical charges. By clicking this box, you DO AGREE with this permission.

First Aid & CPR Permissions *

I give permission for certified staff to administer First Aid and CPR to my child.

Medical Treatment Permissions *

I authorize Timberlake personnel to administer routine medical treatment (band-aid, antiseptic, etc.).

Transportation Permission *

The undersigned does also hereby give permission for our (my) child/student to ride in any vehicle driven by an approved ADULT chaperone over the age of 25 while attending and participating in activities sponsored by Timberlake Church. My child/student and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation. By clicking this box, you DO AGREE with this permission.

Early Return Home Policy *

Should it be necessary for our (my) child/student to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibilities. By clicking this box, you DO AGREE with the Early Return Home Policy *

Photo Release Policy *

I agree Timberlake may photograph and/or record my child/student/dependent’s likeness during activities. I grant rights to Timberlake: to use and re-use, publish and re-publish, and modify or alter the image(s) or video taken. Use of images for editorial, commercial, trade, advertising, and any other purpose in any medium now existing or subsequently developed, on Timberlake's website, social media, print material and other forms of media/communication, and worldwide in perpetuity for purposes stated above. I waive my right to inspect or approve any editorial text or copy that is used in connection and release/discharge Timberlake from any and all claims arising out of the use for purposes described above, including claims for libel, invasion of privacy, or other tortuous act. I have read the foregoing and understand its contents, and this agreement does not expire, and confirm by clicking the "I Agree" button below. I am over 21 and have legal capacity to agree to the release.

YES, I agree

NO, I do not want my child's photo or video used for Timberlake's Communication Ministry.

Parent/Guardian Signature *

By checking "I Agree" below, gives an acknowledgment that I have read and understood these guidelines. I recognize that this is an annual permission slip to cover from January 1, 2024 - December 31, 2024. I commit to abide by the provisions of this Permission Form and submit to Timberlake Children and/or Student Ministries. By clicking the box, you are signing this form *

Household members

Please let us know any additional ADULT members that live in your household. DO NOT add additional children. Each child will need their own form annually for insurance and policy procedures.

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