2023-24 TSM General Permission/Medical/Contact Form - Student UNDER 18yo

Student Name

Student Phone

Student Email

Date of Birth

Class of 20__

Gender

School

Full Address

Parent Name(s)

Parent Email

This address will receive a confirmation email

Secondary Parent Email

This address will receive a confirmation email

Mother's Phone

Father's Phone

Emergency Contact

In the event of an emergency give the name and phone number of a relative or friend we can contact who will know how to locate parents or legal guardian:

Emergency Contact Name #1

Phone

Relation to student

Emergency Contact Name #2

Phone

Relation to student

The undersigned (i) is/are the parent(s)/legal guardian of the above-named student, a minor, (the “Student”); and (ii) represent that they have the authority without the consent of any other and without any condition or qualification to execute this permission/authorization on behalf of the Student. Each of the undersigned also acknowledges that this permission/authorization is binding upon him/her.

The Student has the undersigned’s permission during the period indicated above to participate in any youth activity intended for the Student’s age offered or sponsored by the Thornapple Covenant Church (“Thornapple”) through its youth ministry or otherwise. To the extent a separate permission/authorization form is also required by Thornapple for a particular activity (e.g., an out-of-state trip or a high adventure event), the two shall be interpreted as complementing each other to the fullest extent possible. However, in the event there is an ambiguity or contradiction between the two forms, the specific activity permission form will control.

General Release

The undersigned represents that he/she (i) has reviewed and will continue to review with the Student all general policies posted on Thornapple’s website concerning church activities generally and youth activities specifically; and (ii) will review with the Student any special posting or handout concerning a particular activity (e.g., an out-of-state trip or a high adventure event) prior to the Student participating in that particular activity.

The undersigned understands that the Student is expected to comply with all Thornapple policies applicable to that activity and to otherwise behave in a manner (i) that is lawful; (ii) that does not endanger the Student’s health or the health of others; (iii) that is not disrespectful of others; (iv) that does not disrupt the activity; and (v) that does not destroy or deface property. If, in the judgment of the activity’s leader the Student does not conform with these expectations, the undersigned understands and agrees that the Student may be separated from the others and, depending upon the circumstances, (i) be directed to leave; (ii) be immediately picked up by the undersigned, or (iii) be returned home by an appropriate form of transportation at the undersigned’s expense.

The undersigned agrees that if the Student is suspected of being in possession of something not permitted by Thornapple’s policies or that is otherwise inappropriate for a church sponsored activity (e.g., a controlled substance, a weapon, alcohol, tobacco, fireworks, or media with indecent content), the Student’s personal property may be searched provided that the search is conducted privately by an adult and with at least one other adult observing. Moreover, the undersigned agrees that whatever unpermitted or inappropriate item is found may be confiscated and either turned over to the appropriate authorities or to the undersigned.

The undersigned agrees that in the event an activity is photographed or otherwise recorded, the Student may be included in that photograph or other recording. The undersigned also agrees that the photograph or other recording (or a copy) may be kept by Thornapple for its records and may be used by Thornapple at any time to promote itself or its mission.

Medical Release

The undersigned represents that the separate medical and pharmaceutical form for the Student for the period indicated above has been completed and returned and that the form will be updated as need be during that period.

The undersigned agrees that the Student may attend a Thornapple youth activity only if (i) the Student’s physical, mental and emotional condition is good at that time; and (ii) to the best of the undersigned’s knowledge, the Student has within (10) days prior to the activity not been exposed to either the COVID 19 virus or any other infectious virus or bacterium.

The undersigned understands that (i) Thornapple will comply with all federal and state laws relating the COVID 19 virus or any other infectious virus or bacterium; and (ii) Thornapple will adopt whatever other health policies it determines in its sole judgment are appropriate to minimize the spread of infectious viruses or bacteria. The undersigned also understands that it is still the undersigned’s individual responsibility (i) to personally assess the safety of the health policies to be followed for a particular activity; and (ii) if the undersigned is not satisfied, to not allow the Student’s participation in that activity.

The undersigned understands that in the event the Student requires medical or dental treatment, the activity’s leader will make a reasonable effort to contact the undersigned before a procedure is performed or a treatment administered unless i) the procedure or treatment is minor (e.g., irrigating an eye or administering antibacterial ointment and a band aid to a small wound); or ii) the procedure or treatment is authorized in the health form on file.

The undersigned also agrees that if the undersigned cannot be reached even after a reasonable effort under the circumstances or the circumstances require immediate action, then the activity’s leader (or the staff person or volunteer designated by that leader) has my unconditional permission and authorization to make all medical and dental decisions on behalf of the Student related to the medical or dental situation (including, but not limited to, on-site or in-transit emergency treatment, anesthesia, bloodwork and other tests, X-ray and other radiological exams, medical, dental or other invasive procedures, administration of drugs, blood transfusions, and out-patient or in-patient admission) and this authority will continue until the undersigned can be reached and put into a position to assume responsibility for making medical or dental decisions on behalf of the Student. This authority also includes signing any document required by the medical or dental provider in connection with the treatment or procedure to be provided, including releases, waivers, and any document required under HIPAA. Medical and dental decisions under this authority shall be made only in consultation with a doctor or dentist (as the case may be) who is licensed to practice in the state where the services are rendered unless the immediacy of the situation requires the decision to be made without consultation, in which case the decision may be made upon the best information and advice available at that time.

Student's Physician

Physician's Phone

Medical/Hospital Insurance Company

Policy/Group Number

Phone Number

Dental Insurance Plan

Policy/Group Number

Phone Number

Preferred Pharmacy

Phone Number

Please describe any other medical conditions that Thornapple should be aware of (e.g. ADHD, Asthma, Diabetes, Headaches/Migraines)

Allergies

Does Student or Adult participant carry on their person an EpiPen or fast acting or rescue inhaler?

Is Student/Adult participant current on immunizations, including for Covid virus?

Describe any dietary restrictions that this student is required to observe

Does Student/Adult participant take any prescription medications? If yes, please list each medication, the reason for the medication, and the prescribed dosage (e.g. amount & times per day)

Is Student or Adult participant restricted from participating in any physical activity? If yes, please explain

What other medical information should Thornapple know about the Student or Adult participant that would be helpful in ensuring his/her safety when participating in a Thornapple youth activity?

The undersigned represent(s) that the information provided in response to these questions and requests is complete and accurate and that the undersigned will update this form if there has been any material change in the Student or Adult participant’s health or medical condition or in the emergency contact information.

Parent(s)/Guardian Signature for Student Participant under 18 years old

The undersigned (i) is/are the parent(s)/legal guardian of the above-named Student participant, a minor; and (ii) represent that they have the authority without the consent of any other and without any condition or qualification to execute this form on behalf of the Student participant. Each of the undersigned also acknowledges that this permission/authorization is binding upon him/her.

Consent

To the best of my knowledge, I have listed all of my child's medical allergies, medications being taken, medical problems, and other pertinent information. My child has permission to participate in all prescribed activities except as noted by me.

Electronic Signature of Parent or Legal Guardian

Date of Electronic Signature

*By entering my name in the text box above, I am providing my digital signature on this form

Comments or Questions?

Description

9/1/2023 - 8/31/24

Please fill out this form (one for EACH student) to participate in any TSM outing, excursion, trip, or retreat. This form will be applied to any and all of such events happening between 9/1/2023 and 8/31/2024.

2023-24 TSM General Permission/Medical/Contact Form - Student UNDER 18yo

Description

Please Fix the Following