Commission CollAb Consent Form

Parent/Guardian - Please complete the first part of this form using your student's information. If your student does not have an email address please use your own.

Your name *

Email address *

Birthdate

Phone number

Parent/Guardian Information

Parent/Guardian Name (1) *

Name & Relation to Student *

Parent/Guardian Phone (cell phone) *

Parent/Guardian Name (2)

Medical Information

By submission of this form, and in the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital/doctor. In the event of an emergency, if you are unable to reach me at the numbers listed above, please reach out to the emergency contact.

Medical note

Please list any allergies, medical conditions or medication we should be aware of.

Primary Care Doctor *

Primary Care Phone Number *

Insurance Provider *

Insurance Policy # *

Emergency Contact Name (different from adult/s listed above) *

Emergency Contact Phone (different from phone number/s listed above) *

Emergency Relation (different from adult/s listed above) *

Liability Release Statement

By submission of this form, I (the parent/guardian of the student listed) grant permission for my student to participate in Commission CollAb activities and programs, including those that require transportation to a location away from the Commission Church site. Commission CollAb events will take place under the guidance and direction of Commission Church Staff Members and Commission CollAb staff and volunteers.

Locations will be specified in event promotional materials and may include regular youth programming, one-on-one discipleship, pool parties, park activities and sports, mission trips, summer camp and conferences, beach trips, theme parks etc.

As parent/legal guardian, I acknowledge that I remain legally responsible for any personal actions taken by the above named student (participant). Submission of this form serves as my signature.

Please type your name (in place of signature) *

Today's Date *

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