Parental Consent and Medical Care Authorization

Child’s Name ____________________________________________________________________________________________________

I, the undersigned, being the parent or legal guardian of the child named on this application, do hereby release from liability and to indemnify and hold harmless Celebrate KIDS! and Celebration Church of God, 4429 Buck Mountain Road, Roanoke, VA 24018 and any of its employees or agents representing or related to the Celebrate KIDS! program.  This release is for any and all liability for personal injuries (including death) and property losses or damage occasioned by, or in connection with any activity or accomodations while my child is in the care of Celebrate KIDS!.

I, the undersigned, being the parent or legal guardian of the child named on this application, do hereby consent to the participation of my child in any and all field trips (including riding the school van/bus) planned by Celebrate KIDS! (4429 Buck Mountain Road, Roanoke, Virginia, 24018) for as long as my child is enrolled.  I also certify my child is physically fit and adequately trained to participate in such events unless noted aboveI understand that I will be notified in the case of a medical emergency involving my child; however, in the event that I cannot be reached, I authorize provisions to be made concerning my child’s health should he/she become injured or sick.  

I understand that Celebrate KIDS! will not be responsible for medical expenses incurred, but I will be fianancially responsible for the treatment.  I agree to notify Celebrate KIDS! verbally and in writing of any changes to my child’s health status. 

I have read and will comply with all of the rules and regulations put into effect by Celebrate KIDS! as set forth in the Policy Handbook.

If applicable, both parents or guardians are required to sign this form.

______________________________________________________________________________ (Date)

______________________________________________________________________________ (Date)

NOTE: A copy of your child’s immunization records, and birth certificate must be on file in the office prior to starting the program.