To be completed by a parent or legal guardian
Please complete this form for each minor participating or volunteer serving or leading at Dream City Church ("Dream City Church" or "DCC") activities, events or trips occurring both on and off campus.
Name of minor:
Date of birth:
Name of School:
Minor's Phone: (Area) Phone number:
Mother’s full name:
Mother’s cell phone: (Area) Phone number:
Father’s full name:
Father’s cell phone: (Area) Phone number:
Legal Guardian (if applicable):
Guardian's cell phone: (Area) Phone number:
In the absence of parent or guardian, Dream City Church may contact:
Phone: (Area) Phone number:
Medical Phone number:
Is tetanus immunization current:
Are your child’s shots up to date?
Is there anything that will prevent or restrict child’s participation in any activity?
I am the parent or legal guardian of the child named above. I warrant that I possess all the rights, powers and privileges of a parent or legal guardian necessary to execute this legal instrument with binding legal effect.
I consent to the examination or treatment of my child by a physician duly licensed to practice medicine or any health care professional duly licensed to provide health care services for medical care and services deemed necessary by Dream City Church, its agents, servants, and employees. I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary.
I understand and acknowledge that my permission and consent is sufficient for this purpose. I represent to Dream City Church that no permission or consent from any other person is required by law.
I agree to pay for any and all medical expenses incurred as a result of the use of this consent.
I understand that it is my obligation to inform the management of Dream City Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while at Dream City Church or involving Dream City Church or its programs.
Should the need for medical attention arise, Dream City Church will attempt to contact you, as soon as practicable under circumstances.
This permission is valid for one full year and will expire the following year on the date given below.
Release of Liability and Indemnification:
I am the parent or legal guardian of the child named on the previous page. I warrant that I possess all the rights, powers and privileges of a parent or legal guardian necessary to execute this legal instrument with binding legal effect.
As a parent or legal guardian of the child named on the previous page, I certify and affirm that I have been completely and thoroughly informed that as a youth attending Dream City Church, my child will participate in certain activities which carry with them a degree of risk and danger.
Examples of risky and dangerous activities include, but are not limited to:
- Physical activities, both indoors and outdoors
- Sports, both informal and organized
- Use of recreational equipment
- Field trips, both on and off campus
- Travel by automobile
- Activities around water, including swimming, boating, baptism
- Hiking, camping
- Construction, and maintenance projects
I acknowledge and understand that Dream City Church may offer other activities not listed above that present similar risks or dangers to my child. I consent to my child’s participation in these activities. I acknowledge and understand that this PARENTAL CERTIFICATION, CONSENT, AND RELEASE has the same force and effect regardless of whether the activities engaged in are free or if a fee is charged. Further, I personally assume, on my child’s behalf, all risk in connection with said activities for any harm, injury or damages that may befall my child as a result of my child’s participation in the activities, whether foreseen or unforeseen, and I still wish to allow my child to proceed with the activities. I acknowledge and agree that Dream City Church shall not be held liable in any way for any occurrence resulting directly or indirectly from these activities that results in injury, death, or any other damages to my child, me, or my family, heirs, or assigns. In consideration of my child being allowed to participate in these activities, on behalf of my child, I hereby personally assume all risk in connection with said activities, for any harm, injury, or damage that may befall my child, me, or my family, heirs, or assigns while engaged in such activities.
I understand that the terms herein are contractual and not mere recital; I have signed this document as my own free act. It is my intention by signing this document to exempt and release Dream City Church from all liability whatsoever for personal injury, property damage or wrongful death caused by negligence. I further acknowledge and agree that my signature on this PARENTAL CERTIFICATION, CONSENT, AND RELEASE shall constitute a bar to any recovery by my child, me, or my family, heirs, or assigns in all suits and actions that may be instituted against Dream City Church, its agents, servants or employees for injuries or death to my child, whether or not same resulted from the negligence of Dream City Church, its agents, servants, or employees, or due to the negligence of my child, or due the risks ordinarily incident to my child’s participation in these activities, or due to the contributory negligence of my child. I understand that it is my obligation to inform the management of Dream City Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities involving Dream City Church or its programs.
I have fully informed myself of the contents of this PARENTAL CERTIFICATION, CONSENT, AND RELEASE by reading it before I signed it. This form is valid for one full year and will expire the following year on the date given below.
Release of Media Rights:
I give Dream City Church permission to publish in print, electronic, or video format the likeness or image of my child including audio recordings of my child. I release all claims against Dream City Church with respect to copyright ownership and publication including any claim for compensation related to the use of the materials.
Images, videos, and audio recordings of my child taken or recorded by Dream City Church can be used in print, broadcasting, and in other forms of advertising; brochures, newsletters, and other church publications on the Dream City Church website; in audiovisual presentations; and in other activities to promote Dream City Church and inform the public about Dream City Church without payment of feeds, royalties, or other remuneration.
When images are published, Dream City Church will take cautionary steps to provide minimum identifying information and will not use specific street or mailing addresses, e-mail addresses, or phone numbers.
Signature of a parent or guardian: