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Child's name:
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Age / Birthdate:
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Your phone number:
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Your email address:
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Allergies:
To food or anything
else
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Address:
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Parent/Guardian Name
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Cell Phone or
Emergency Contact #
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Does your child have
any current illnesses?
Or taking any
medication? If yes,
please note
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Does your child have
a physical handicap
or illness that would
prevent him or her
from participating in
normal rigorous
activity? If yes, please
note.
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Family Doctor?
Please note
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Can your child have
their photo taken at
Kid's Night?
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Medical Insurance?
If yes, list company
and policy number
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Any special needs, or
personal
considerations we
need to be aware of?
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Consent and Certification
I, the undersigned, being the parent or legal guardian of the youth named
above, do hereby consent to the participation of my youth in all the
scheduled youth and kid’s night activities of House of Prayer Church of
Post Falls, Idaho, and any other supervised activities customarily
associated with its Kid’s Night activities. I certify that my youth is
physically fit and adequately prepared to participate in all recreational
events. If I wish to revoke this consent for any reason, I will promptly
notify a Kid’s Night leader in writing. Medical Treatment Authorization- I
understand that I will be notified in the case of a medical emergency.
However, in the event that I cannot be reached, I authorize the calling of a
doctor and the providing of necessary medical services in the event that
my youth is injured or becomes ill. I authorize one or more of the following
persons to make emergency medical care decisions on behalf of my
youth, if required by law or a health care provider: Kimberlee Burke,
Kenneth Carroll or another adult chaperone designated by the activity
leader. I authorize these persons to act in my place to consent to all
necessary and appropriate x-ray examinations, anesthetic, medical or
surgical diagnosis or treatment, and hospital care.
I understand that House of Prayer will not be responsible for medical
expenses incurred solely on the basis of this Authorization. I further
agree to notify the activity director in writing of any health changes that
would restrict my youth’s participation in any normal youth recreational
activities. I also understand that the activity leader and designated adult
chaperones reserve the right to restrict my youth from any activity that
they do not feel is within the physical capabilities of my youth.
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Check box, if you consent to the above.
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Parent's/
Guardian Initials
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