Insurance, Permission & Emergency Form, 2020-2021

If you have children ages 0-12th grade, please fill in the form below. It will only take a few minutes of your time!

This ensures that you are on the right email distribution lists, that we have your input on use of photos of your children, allergies, medical information, etc., and youth are included in communications for upcoming service and social activities!

Even though our meetings and activities may not look the same as before due to our health climate, it is still important for us to gather this information. Thank you for understanding!

PARENT/GUARDIAN INFO

This address will receive a confirmation email

Is this Parent/Guardian the primary contact for your child's scheduling?

Yes No

Address (not required if same as parent #1)

Is this Parent/Guardian the primary contact for your child's scheduling? Yes No

Please list who is approved to pick up your children from FCC events.

Last Name, First Name

Grade in '20-'21

Allergies (please write "N/A" if none)

Please note that due to COVID-19, the following events will be restricted or modified and are therefore not included in the participation list below:

Junior Choir
Youth Band at Come As You Are
Nursery Care
Paid Teen Nursery Workers

Participation Interests (Check all that apply)

Church School (age 3-grade 5) Elementary Events 3rd Grade First Communion 4th Grade Bibles Confirmation (grade 8) Access (Grades 5 - 8) Youth Group (grades 6-12)

Cell Phone (if in grades 6-12)

E-mail (if in grades 6-12)

Last Name, First Name

Grade in '20-'21

Allergies (please write "N/A" if none)

Participation Interests (Check all that apply) Church School (age 3-grade 5) Elementary Events 3rd Grade First Communion 4th Grade Bibles Confirmation (grade 8) Access (Grades 5-8) Youth Group (grades 6-12)

Cell Phone (if in grades 6-12)

E-mail (if in grades 6-12)

Last Name, First Name

Grade in '20-'21

Allergies (please write "N/A" if none)

Cell Phone (if in grade 6-12)

E-mail (if in grade 6-12)

Last Name, First, Name

Grade in '20-'21

Allergies (please write "N/A" if none)

Participation (Check all that apply) Church School (age 3-grade 5) Elementary Events 3rd Grade First Communion 4th Grade Bibles Confirmation (grade 8) Access (Grades 5 - 8) Youth Group (grades 6-12)

Cell Phone (if in grade 6-12)

Email (if in grade 6-12)

Please list any additional information you would like us to know about your children or your family, including special accommodations

From time to time, pictures are taken and used in church publications, the FCC website, on the Church Social Media accounts, and in the newspaper. If you do not wish to have your child/children's picture used in this way, please check NO. If it is acceptable to use your child/children's picture in this manner, please check YES.

Please note that most events will be photographed generally, but we will take care to not feature, post or tag you or your child if you wish.

Photo Permission

Yes No

LIABILITY AND EMERGENCY RELEASE

I give permission for Mrs. G., Rev. Terry, Pastor Ben, and church school teachers to communicate with my child electronically over Zoom or other live platforms during church events. In keeping with safe church policies there will be at least two Safe-Church approved adults observing, in the "room", or participating in live electronic communications involving the youth or children of FCC.

Please indicate your agreement to the above statement:

I agree Not applicable

If I provide my child's cell phone number, I give permission for Mrs. G. and Pastor Ben to text my student regarding events and with encouragement, bible verses, and appropriate check-ins.

If my child provides their cell phone number to Mrs. G. or Pastor Ben, I will receive a notification and be asked for my (the parent) permission to interact with that child over text.

Please indicate your response to the above statement:

I give permission for FCC ministers to text my child I do not give permission for FCC ministers to text my child Not applicable

I hereby give permission for my child/children listed above to participate in 2020/2021 activities and events. I hereby agree to indemnify and hold the First Congregational Church of Darien, CT, and the employees and agents harmless from any and all liability as a result of my child being involved. A separate release form will be given to parents for any over-night trips or transportation arrangements.

Please indicate your agreement to the above statement:

In the event I/we cannot be reached during a medical emergency or following any accident, I authorize the staff of the First Congregational Church of Darien to act in my/our behalf in carrying out the best treatment possible in consultation with my child's attending Board Certified and licensed physician at an accredited medical facility.

Please indicate your agreement:

Additional notes or information:

In the event I/we cannot be reached during an FCC activity or meeting, please contact the following individuals:

Insurance, Permission & Emergency Form, 2020-2021

Description

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