The following information received is confidential and is being gathered for the purpose of serving your youth while in the care of Russell AllianceChurch. Any medical information collected here serves to authorize Russell Alliance Church, and its staff/volunteers to obtain medical assistance in emergencies.This form is to be completed annually by parents/caregivers.
The safety of your Children/Youth is our primary concern. Precautions will be taken for their well-being & protection.
I/we, the Parents or guardians named above, authorize one of Russell Alliance Church Child/Youth Program Personnel to sign a consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above.
I/we, named above, undertake and agree to indemnify and hold harmless Program Personnel, Russell Alliance Church, and its leaders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Russell Alliance Church, as well as of any medical treatment authorized by the supervising individuals representing Russell Alliance Church. This consent and authorization is effective only when participating in or traveling to events sponsored by Russell Alliance Church.
Communication (applicable only for youth ages 11-17):
A policy is in effect that communication with youth is to be closely monitored (via group chat forums or apps such as FaithSpark or similar) and only used with parent/guardian consent.
Media Release (applicable for all ages):
Dismissal Authorization (applicable only for children/youth over the age of 6):
Special Instructions for Ministry Personnel:
Purposes and Extent
Russell Alliance Church is collecting and retaining this personal information for the purpose of enrolling your children/youth in our programs, to assign them to the appropriate classes, to develop and nurture ongoing relationships with you and your children/youth, and to inform you of program updates and upcoming opportunities at Russell Alliance Church. This information will be maintained indefinitely as it is a requirement of our insurance company and legal counsel. If you wish Russell Alliance Church to limit the information collected, or to view your children/youth’s information, please contact us.
Parent/Guardian Options
I have read, understood and agreed with the above and signed it to cover all Children/Youth Program activities for the program year effective as stated above. A separate Informed Letter of Consent will be sent home for off-site activities and activities of elevated risk.