NEXTGEN: Parent Consent & Release of Liability Form

Please complete one form for each child. A completed Parent Consent & Release of Liability Form is required for participation in any Piedmont Community Church activity, including regular Sunday NextGen participation.

Your name *

Email address *

Student Name and Grade *

Allergies or Restrictions *

Release of Liability *

My son or daughter has my (our) permission to attend and participate in Piedmont Community Church events. I (we) agree to waive, release, and hold harmless Piedmont Community Church, its officers, agents, employees, and volunteers from and against any and all claims, costs, liabilities, expenses or judgments, and hereby agree to indemnify and hold harmless Piedmont Community Church from and against any and all such claims.

Consent to Treat - please check one of the boxes below *

Church leaders have my (our) consent to obtain medical attention if necessary.

Church leaders do not have my (our) permission to obtain medical attention if necessary.

Photo/Video Release - please check one of the boxes below *

Church leaders have my (our) permission to take/use photos or videos of my child for use on social media or the church website.

Church leaders do not have my (our) permission to take/use photos or videos of my child for use on social media or the church website.

Medical Consent Form - please check one of the boxes below *

Medical personnel have my (our) permission to administer medical attention if necessary, including anesthesia.

Medical personnel do not have my (our) permission to administer medical attention if necessary, including anesthesia.

Address *

Home Phone *

Cell Phone *

Work Phone *

Student's Date of Birth *

Insurance and Policy Number *

Secondary Insurance and Policy Information

Emergency Contact - Name and Phone Number *

(Other than Parent/Guardian)

This Consent & Release from Liability Form shall remain effective for one year from date below, unless otherwise revoked in writing and delivered to any officer, employee, or agent of Piedmont Community Church. *

* By checking the box I agree to the terms and approve the use of my electronic signature.

Parent/Guardian Name - Electronic Signature *

*The name input in this field serves as your electronic signature.

Signature Date *

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