The Gate Church Student/Child Consent Form

Consent/Medical Permission Form

Effective Dates: September 1,2024 — August 31, 2025

PARENT/ GUARDIAN INFORMATION

Your name *

Email address *

Gender *

Phone number *

Address *

Are there any alternative phone numbers you can be reached at?

Household members

Please add your Student/Child's information here and any other Parent or legal guardian information.

Does the Student/Child live with the Parent or Guardian filling out this form? *

Does the Student/Child have their own Phone Number? *

If YES, Please provide it in the event of an emergency. If there are MULTIPLE Students/Children with phones, Please let a staff member know and we can update their profile after this from is complete.

Would you like to add any ADDITIONAL ADULTS as an emergency contact?

PARENTAL CONSENT:

The undersigned does hereby give permission for my child to attend and participate in any The Gate Church children/youth ministry activities, events, retreats and childcare during the period of September 1, 2024 – August 31, 2025.

LIABILITY RELEASE:

In consideration of The Gate Church allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless The Gate Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION:

I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY

Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION:

The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by The Gate Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

ELECTRONIC CONSENT: *

Please select whether you give CONSENT to these terms as listed above

ELECTRONIC CONSENT DATE (Today's Date) *

MEDICAL INFORMATION:

PRIMARY CARE PHYSICIAN:

Name:

PRIMARY CARE PHYSICIAN:

Phone Number:

NAME OF PRACTICE:

Date of last Tetanus Shot: *

INSURANCE INFORMATION:

Medical Insurance Company:

Medical Insurance:

Phone Number:

Policy Holder's Name

Policy/Group ID#:

If a copy of the Medical Insurance Card is available, we may ask for this to make copies.

MEDICATION:

Please list all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

MEDICATION:

Please list any prescription or non-prescription medication that the Student/Child or Children will need to take while at this event. Please be sure to list all the necessary information.

Example:
Name of Student/Child:
Medication Name:
Dose:
Treatment for:
Dispensing instructions (How often, with food or without):

Over-the-Counter Medication Permission: *

Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

ELECTRONIC CONSENT DATE (Today's Date) *

MEDICAL CONDITIONS:

Please answer in detail if applicable or write N/A. Attach additional pages if necessary.

1. List any medical conditions you have (asthma, diabetes, epilepsy, etc.):

2. List any allergies (drug/medicine, food, and/or environmental) and the severity and type of reaction:

3. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.

The Gate Church Student Ministry Covenant of Community Expectations

The following rules and guidelines are equally binding on adult leaders/chaperones and student.

NON-NEGOTIABLE RULES:

Any participant failing to abide by these rules will be sent home immediately at personal/family expense.
• No use of illicit drugs or alcohol
• Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions
• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)
• Must be in assigned rooms by designated time
• Coed visitation only in assigned community room
• Smoking and the use of tobacco products are not allowed to, from, or during any trip.
• Will not break any American laws in the United States or any other country.

GUIDELINES FOR LIVING IN CHRISTIAN COMMUNITY:

• Adults and students will be equally responsible for performing assigned tasks in a timely and cooperative manner.
• Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other.
• Participants will be respectful of both common living spaces and the property of others.
• Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.
• Sleeping areas for males and females will be separate.

Student/Child Participant’s (or Adult Leader’s) Statement:

By selecting I AGREE in this form, I pledge to honor God and respect others during this activity by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.

ELECTRONIC CONSENT: *

Please select whether you AGREE to these terms as listed above:

ELECTRONIC CONSENT DATE (Today's Date) *

Parent/Guardian’s Statement:

By signing this form, I agree to support the Covenant of Community Expectations printed above, and will accept responsibility for the payment of my child’s return transportation should s/he break one of the non-negotiable rules. By selecting I AGREE, I am acknowledging that I have reviewed ALL non-negotiables with my Student/Child(s) that will be participating.

ELECTRONIC CONSENT: *

Please select whether you AGREE to these terms as listed above:

ELECTRONIC CONSENT DATE (Today's Date) *

The Gate Church Photo Release Form for Children and Students

I agree that The Gate Church may photograph and record my child/dependent’s likeness and activities (Images)1 during church-related activities. I grant the following rights to The Gate Church: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge The Gate Church from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.

ELECTRONIC CONSENT: *

Please select Yes photos ARE allowed if you agree to these terms as listed above:

ELECTRONIC CONSENT DATE (Today's Date) *

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