Kids Church Waiver Form (September 1, 2025-August 31, 2026)

Kids Ministry Authorization and Consent – Annual (Ages 0-11)

Philpott Memorial Church is collecting and retaining this personal information for the purpose of enrolling your child or youth in our programs, to assign the student to the appropriate classes, to develop and nurture ongoing relationships with you and your child or youth, and to inform you of program updates and upcoming opportunities at our church. This information will be maintained permanently as it is a requirement of our insurance company and legal counsel. If you wish Philpott Church to limit the information collected, or to view your child’s information, please contact us.

Your name *

Email address *

Parent/Guardian Information

In the case of custody agreements, please provide us with the proper forms authorizing parental contacts.

Parent/Guardian #1 Name *

Address *

Phone number *

E-Mail *

Parent/Guardian #2 Name

Address

Phone number

E-Mail

Emergency Contact Information

If parent/guardian is not available

Emergency Contact Name *

Phone number *

Relationship to Child *

Waiver Info & Release

If I/we cannot be reached in an emergency,

I/we, the parents or guardians named above, authorize the Philpott Memorial Church Ministry Staff to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named above, undertake and agree to indemnify and hold blameless the Ministry Staff, Philpott Memorial Church, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Philpott Memorial Church, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of Philpott Memorial Church.

The safety of your student is our primary concern. Precautions will be taken for their well-being and protection.

Photo Release

We occasionally take photos of the children/youth during church activities. May we use these pictures for church ministry promotion? *

Yes

Student Information

Student Name *

Birthdate *

Gender *

Address *

Grade as of September 2025 *

Please list any allergies, medical conditions, dietary restrictions

Does your student have any physical, emotional, mental, or behavioural realities that we can help facilitate? If so, please explain

Please list any medication this youth will be bringing with them

[Only for Older Elementary] Ability to Release Student without Parent/Designate Present *

For students in our older elementary class, do you agree that they can be released once the service ends without a parent or designate present?

Yes

[Only for Early Elementary] Ability to Release Student by an Alternate Designate

For students in our early elementary class, they can be released by an alternate designate besides a parent, but only if we know about the designate beforehand. If you would like to designate someone besides yourself (parent/guardian #1 or parent/guardian #2) please list them below. PLEASE NOTE SIBLINGS MUST BE IN GRADE 6 OR OLDER TO BE CONSIDERED A DESIGNATE.

Parent/Guardian Signature

Electronic Signature *

By entering your name in the box below you are providing an official signature on this form, thereby indicating that all information above is accurate

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