Essential Contact and Safety Information

SMC Children's Ministry 2022 - 2023 Registration and Parental Consent Form
If you have more than three children enrolled please contact Sarah Scorzetti for more forms

General Contact Information:

Parent (Guardian's) Name * First Last
insert your name
Home number * - (###) - ### ####
Work number * - (###) - ### ####
Cell number * - (###) - ### ####
Email *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Both parents (guardians) share the same address * Yes no
Parent (Guardian's) name * First Last
Home number - (###) - ### ####
Work number - (###) - ### ####
Cell number - (###) - ### ####
Email
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
CHILD PICK UP CONSENT:

The following individuals may pick up my child(ren) from Sunday School and/or Kid Connections (Wed nights).

Note: siblings in 6th - 12th grade may pick up their sibling if their name is listed on this sheet

Name of authorized person * First Last
Relationship to child *
Name of authorized person * First Last
Relationship to child *
MEDICAL INSURANCE INFORMATION:

Medical insurance * Yes No
Insurance Carrier *
Policy # *
Physician *
Phone * - (###) - ### ####
Dentist * First Last
Phone * - (###) - ### ####
Name(s) of insured children
Name of insured children * First Last
Name of insured children First Last
Name of insured children First Last
Emergency Contact Information:

In case of emergency, please describe the best way to contact you and/or where we can find you during...

Sunday School *
Kid Connections *
In case of emergency, list a relative or neighbor that we should contact if unable to reach parent/guardian

Name * First Last
Phone * - (###) - ### ####
Relationship *
Name * First Last
Phone * - (###) - ### ####
Relationship *
For Nursery (infant-2yr olds) Parents: Please indicate if you would like SMC nursery volunteers to change diapers. Yes, SMC nursery volunteers can change my child's diapers No, have SMC nursery volunteers text me if a diaper change is needed and myself or another authorized adult will change my child's diaper
LETTER OF PARENTAL CONSENT:

I/we (insert your name below) give permission for my children... * First Last
insert your name
Child's name * First Last
insert child's name
Child's name First Last
insert child's name
Child's name First Last
insert child's name
In order to participate in all church-sponsored activities on the church premises, and trips and activities away from the church premises throughout the current school year. Children will be accompanied by a teacher or adult sponsor and will be under adequate supervision. I/we understand that I/we will be given prior notice of all trips away from the church premises. I/we further understand that I/we may revoke permission for a specific activity or trip at any time.

Although the church desires to provide a safe and enjoyable time for all children and youth, accidents can still happen. I/we understand that there are risks/dangers involved with participation in on and off campus events and their associated activities. In consideration of my child being allowed to participate in church sponsored activities or trips, I/we agree to assume responsibility for those risks/dangers associated with the travel and activities. I/we agree to hold harmless Souderton Mennonite Church (SMC), its employees and representatives, including volunteers and drivers, from any and all claims arising from my child’s participation. This release agreement does not apply to claims of intentional misconduct by the church, its employees or volunteers.

In case of an accident, illness, or other emergency, I/we request that SMC contact me/us. If SMC cannot reach a parent/guardian after conscientious effort, I/we give permission for church staff to call paramedics or any licensed physician or dentist. If a life-threatening emergency exists, I/we give permission for the church staff to call paramedics immediately and then contact me/us as soon as possible thereafter.

I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care, which, in the best judgment of a licensed physician or dentist is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for emergency medical transportation. In cases where medical care is needed but the situation is not an emergency, SMC will make every effort to contact the parents/guardians before treatment is given.
I/we give consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my child(ren) during SMC activities, to be used, distributed, or shown through Internet or written publications or as SMC sees fit. * Yes No
I/we have read the above Letter of Parental Consent and are fully familiar with the contents thereof.

Name signature * First Last
insert your name
Date * / MM / DD YYYY
insert today's date
BEHAVIORAL EXPECTATIONS:

So that our actions can be God honoring and peaceable, the following are guidelines that are expected from each child:
- Be an active participant within the group
- Respect property
- Respect one another, staff, and adult leaders
- Respect and comply with event schedules

I have read the above expectations and discussed them with my child(ren)

Parent/Guardian signature * First Last
insert your name
Date * / MM / DD YYYY
insert today's date
Child Specific Information:

Child Name * First Last
insert child's name
Please select * Male Female
Age *
Grade Level *
Birth Date * / MM / DD YYYY
Name of School *
List any allergies (food, medicine, etc.) and severity of reaction: *
List any other important information we need to be aware of (ie: physical limitations, fears, special needs, etc): *
FOR CHILDREN PARTICIPATING IN OFF-CAMPUS AND OVERNIGHT TRIPS, PLEASE COMPLETE THE FOLLOWING QUESTIONS:

Medication(s) being taken: (medications must be given to the trip coordinator in original prescription bottle for all off campus activities and trips.)
Date of last tetanus shot / MM / DD YYYY
Does your child wear glasses: Yes No
Does you child wear contact lenses Yes No
For your child's safety and our knowledge is he/she a: good swimmer fair swimmer non-swimmer
Additional Comments
This form is valid for the current school year, September 1, 2022 through August 31, 2023. This form must be updated on an annual basis. In addition, if there are any changes in your child's medical care provision or needs, please contact the Children's Ministry Director, immediately.

To register additional children please continue below:

Child Name First Last
insert your child's name
Please choose Male Female
Age
Grade Level
Birth date / MM / DD YYYY
Name of School
List any allergies (food, medicine, etc.) and severity of reaction
List any other important information we need to be aware of (ie; physical limitations, fears, special needs, etc)
FOR CHILDREN PARTICIPATING IN OFF-CAMPUS AND OVERNIGHT TRIPS, PLEASE COMPLETE THE FOLLOWING QUESTIONS
Medication(s) being taken: (medications must be given to trip coordinator in orginal prescription bottle for all off campus activities and trips.)
Date of last tetanus shot / MM / DD YYYY
Does your child wear glasses Yes No
Does your child wear contact lenses Yes No
For your child's safety and our knowledge is he/she a good swimmer fair swimmer non-swimmer
Additional Comments:
THIS FORM IS VALID FOR THE CURRENT SCHOOL YEAR, SEPTEMBER 1, 2022 THROUGH AUGUST 31, 2023. THIS FORM MUST BE UPDATED ON AN ANNUAL BASIS. IN ADDITION, IF THERE ARE ANY CHANGES IN YOUR CHILD'S MEDICAL CARE PROVISION OR NEEDS, PLEASE CONTACT THE CHILDREN'S MINISTRY DIRECTOR, IMMEDIATELY.

If you have more than three children to enroll, please contact the Children's Ministry Director for additional forms
To register additional children continue below:

Child name

insert your child's name
Please choose Male Female:
Age
Grade Level
Birth date / MM / DD YYYY
Name of school
List any allergies (food, medicine, etc.) and severity of reaction
List any other important information we need to be aware of (ie; physical limitations, fears, special needs, etc)
FOR CHILDREN PARTICIPATING IN OFF-CAMPUS AND OVERNIGHT TRIPS, PLEASE COMPLETE THE FOLLOWING QUESTIONS

Medication(s) being taken: (medications must be given to the trip coordinator in the original prescription bottle for all off campus activities and trips)
Date of last tetanus shot / MM / DD YYYY
Does your child wear glasses contact lenses
For your child's safety and our knowledge is he/she a good swimmer fair swimmer non-swimmer
Additional Comments

Essential Contact and Safety Information

Name(s) of insured children

FOR CHILDREN PARTICIPATING IN OFF-CAMPUS AND OVERNIGHT TRIPS, PLEASE COMPLETE THE FOLLOWING QUESTIONS