Children’s Form Children's Form Children Information and Release Form The Presbyterian Church of Barrington Children's Ministry Information, Medical History and Release and, Permission slip and Publicity Release form INFORMATIONStudent Name(Required) First Last Age(Required)Birthday(Required) MM slash DD slash YYYY Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code SchoolGradeParent/Guardian Name(Required) First Last Parent/Guardian Email Address(Required) Email Address Confirm Email Address Parent/Guardian Phone(Required)Parent/Guardian Add additional parent or guardian Parent/Guardian Name First Last Parent/Guardian Email Address Email Address Confirm Email Address Parent/Guardian PhoneMEDICAL HISTORY AND RELEASEDoes your child have allergies to medications?(Required) No Yes Please listDoes your child have allergies to: pollens insect bites food other Please listDoes your child have any medical issues we should be aware of?(Required) No Yes Please listConsent(Required)My child may be given acetaminophen, ibuprofen, or antihistamine by the leaders as needed. I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the qualified and licensed physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by the Presbyterian Church of Barrington (PCB) through its accident policy will be used as a backup for what my family’s insurance does not cover. Limited coverage of excess medical expenses is available to the maximum allowed per the church’s insurance policy. I understand all reasonable safety precautions will be taken at all times by PCB and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold PCB, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by my child. I agree to the Medical History and Release PolicyPERMISSION SLIP AND PUBLICITY RELEASE FORMPublicity Release(Required)I recognize that the Presbyterian Church of Barrington uses photographs and video images of events in our publicity materials such as the church website, newspapers, newsletters, and social media and I hereby grant permission for photo/video images of my child to be taken and used for such purposes. Personal information such as names, addresses, phone numbers, etc. will NOT be used. Yes, I give my permission to use my child’s photo/video images in PCB’s publicity materials No, I do not give permission to use my child’s photo/video images CAPTCHA