MEDICAL CONDITIONS: Please answer in detail if applicable. Attach additional pages if necessary.
1. List any medical conditions your child/student has (asthma, diabetes, epilepsy, etc.):
2. List any allergies (drug/medicine, food, and/or environmental) and the severity and type of
reaction:
3. Please explain any other pertinent information about your child/student (i.e. physical, behavioral,
or emotional) that would be important for the adult leaders to know.
PARENTAL CONSENT
I hereby give permission for this child/student to participate in church activities of Mt. Vernon Baptist
Church. This includes all sponsored activities on or off the church property (including any and all
activities involving travel and/or lodging) unless otherwise limited below. I understand that reasonable
precautions will be exercised by the adults chaperoning each event. This permission shall remain in
effect until December 31, 2025 unless terminated in writing.
TRANSPORTATION PERMISSION:
I hereby give permission for this child/student to ride in any vehicle designated by the adult in whose
care my child/student has been entrusted while attending and participating in church activities. I
understand that drivers for all events must be over age 21 and approved by Mt. Vernon Baptist Church.
MEDIA POLICIES:
Students communicate in ways other than the traditional phone call or “snail mail”
. In order to use their
ways of communication and reach them where they are and to invite them to participate in Mt. Vernon
Baptist Church events we are asking permission to do the following:
SOCIAL MEDIA- Mt. Vernon can use Social Media to promote/discuss Children/Student events with
my child/me. I give permission for my child/my image/likeness to be used in any of these promotions.
EMAIL - Mt.Vernon can use email to promote/discuss Children/Student events with my child/me.
TEXT MESSAGES – Mt. Vernon Children & Student ministry uses “ChurchCast,
” Subsplash, and
GroupMe text messaging service to promote events. You will NOT be spammed.
MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care my child/student
has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or
dental diagnosis or treatment and hospital care, to be rendered to my child/student under the general or
special supervision and on the advice of any physician or dentist licensed under the provisions of the
Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The
undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such
medical and dental services rendered to the aforementioned child or student pursuant to this
authorization.