My Grace

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gs Parent/Medical/Transport Waiver

Parents / Legal Guardians of minors are requested to complete this consent form and return it to Grace Students. This form will assist the church and Host Homes for Fam Groups in their efforts to provide for the safety of minors during church-sponsored activities. 
Please complete one for each child. Put the child's name in the first section; parent / guardian information should go in the subsequent fields labeled "Parent/Guardian Name."
Thank you for your cooperation.

*Address Line 1
Address Line 2
*City
*State/Province/Region
*Zip/Postal Code
*Date of Birth:
*Gender:
*What grade is your student this school year?
*Parent/Guardian 1 Name:
Parent/Guardian 1 Address:
Parent/Guardian 1 Cell #:
Parent/Guardian 1 Work #:
Parent/Guardian 2 Name:
Parent/Guardian 2 Address:
Parent/Guardian 2 Cell #:
Parent/Guardian Work #:
Acting Guardian/Grandparent
Acting Guardian/Grandparent Contact #
*Emergency Contact (if parents are unavailable)
*Emergency Contact Phone #:
Physician Name:
Physician Phone:
*Insurance Company:
*Insurance Company Phone #:
*Insurance Policy #:
*List allergies to drugs, foods, and plants
*List regularly taken medications
List physical disabilities or medical conditions that may prevent student from participating in normal, rigorous activity.
Are there any other special considerations?
Medical Release and Waiver
The novel coronavirus ("COVID-19") has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly through person-to-person contact. Grace Church Saint Louis is following guidance from the U.S. Centers for Disease Control and Prevention, the Missouri State Department of Health and other agencies, and has implemented social distancing measures, increased hand-washing and other hygienic practices, and frequent cleaning of common surfaces. Despite such precautions, the risks associated with transmission of COVID-19 remain. The nature of many activities makes it impossible to observe all of the recommended precautions all of the time; for example, children/students may not always be six feet apart, and surfaces may not always be free of viruses and bacterium.
Please enter your initials to acknowledge this statement.
I confirm that I will not permit my child to participate in Grace Student activities if, at any time during the program or activity, my child is showing any symptoms of illness including COVID-19 (including but not limited to fever, dry cough, fatigue, shortness of breath, headache, nausea, chills, or muscle pains). Additionally, I confirm that I will not permit my child to participate in a Grace Students event if, at any time within 48 hours leading up to and during the program or activity, my child has been in contact with any individual diagnosed with COVID-19 or any individual currently waiting for test results confirming the possibility of a COVID-19 diagnosis. I agree that in such situations my child will be unable to participate in Grace Students until: (i) 14 calendar days after the symptoms first appeared and my child is no longer showing any symptoms; or (ii) a healthcare provider has confirmed in writing that my child has tested negative for COVID-19 or that my child's symptoms were not due to COVID-19.
I confirm that I will not permit my child to participate in Grace Students activities if, at any time during the program or activity, my child is showing any symptoms of illness including COVID-19 (including but not limited to fever, dry cough, fatigue, shortness of breath, headache, nausea, chills, or muscle pains). Additionally, I confirm that I will not permit my child to participate in a Grace Students event if, at any time within 48 hours leading up to and during the program or activity, my child has been in contact with any individual diagnosed with COVID-19.
*Please enter your initials to acknowledge this statement.
The nature of many activities makes it impossible to observe all of the recommended precautions all of the time; for example, children/students may not always be six feet apart, and surfaces may not always be free of viruses and bacterium. As a result of participation in the activities of the ministry and proximity to other participants, myself or my child will be exposed to the RISK of infection of communicable diseases, including COVID-19. I understand that Grace Students cannot prevent the possible transmission or contraction of COVID-19 for my child.
Please enter your initials to acknowledge this statement.
The undersigned agrees to release, discharge, hold harmless and indemnify Grace Church Saint Louis, its agents, employees, volunteers, and others acting on the church's behalf (the "Releasees"), of and from any and all claims, demands, causes of action and/or legal liabilities for injuries to or death of my child occurring during or resulting from participation in the above mentioned program or activity and related in any way to COVID-19, even if the cause, damages or injuries  are alleged to be the fault of or alleged to be caused by the negligence or carelessness of the Releasees.
Please enter your initials to acknowledge this statement.
Transportation Release and Medical Consent/Certification
Should it be necessary for my child to be transported in a Grace Church - Saint Louis vehicle, staff member's or volunteer's vehicle, I do hereby agree to hold the staff member, volunteer, and Grace Church - Saint Louis harmless of any liability arising from injury, accident or damage, and release and further discharge Grace Church - Saint Louis and its staff and volunteers, and its respective successors, heirs, assigns, agents, officers, directors, shareholders and servants, and all other persons, firms, and corporations, from any injury, accident or damage whatsoever caused to any person, firm or corporation, from and against all loss, reasonable counsel fees, expenses and liabilities incurred on or about any such claim, action or proceeding brought thereon, which I may not have or hereinafter assert against Grace Church - Saint Louis and/or its staff or volunteers with respect to my riding in the church's, staff's, or volunteer's vehicle, or arising from any injury, accident or damage whatsoever cause to any person, firm or corporation.

I, as the parent/legal guardian of the above named student hereby consent to the participation of my child in all of the activities of Grace Students at Grace Church - Saint Louis, including Fam Group/Host Homes, field trips/outings, camp, swimming, boating, hiking, sporting events, and any other activities customarily associated with a church's ministry. Furthermore, I certify that my child is physically fit and adequately trained to participate in such events. I also authorize Grace Church - Saint Louis and its staff members or volunteers to consent for any necessary medical treatment should I be unavailable to authorize said treatment. I agree to be financially responsible for any charges incurred for the necessary treatment of my child. I do understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child.
By signing below, I give  permission for my child/ward, named above, to participate in Grace Students at Grace Church  -Saint Louis.
*Please enter your name as signature to acknowledge this statement.
Thank you for completing this form. Please double-check your answers, and then submit.
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