Open Kitchen Parent Permission Form

Open Kitchen Parent Permission Form 2013-2014 School Year Student Information First Name Last Name Preferred Name (Nickname) Date of Birth /_ / School Attending Grade

Parent/Guardian Relationship Parent/Guardian Relationship Student’s Address City Zip Home Phone Cell Phone E-Mail (Parent/Guardian)

E-Mail (Student) Emergency Contact Name Relationship Emergency Contact Phone Cell Phone Name of Doctor Phone Number Please note any special needs (hearing aids, glasses, leaning disabilities, physical limitations, etc. ) _

Allergies (Food, Medical, or Environment)

Reaction Caused Insurance Information Carrier or Plan Name Group # Name of Insured ID #

Photo/Video Release I hereby consent to and give my permission to Redmond UMC to use my child’s picture, voice, and likeness in it’s programs and activities, including the advertisement and promotion of same in various mediums not limited to RUMC website, print, or RUMC social media.

Parent Signature Date Permission to Administer Medications and Seek Medical Attention I give my permission to Redmond UMC to give the following medication (or the generic equivalents) to my child, in accordance with the recommended package dosing for the specific indications listed below: (Check each one)

 Tylenol for mild fever and discomforts  Antacids for upset stomach  Ibuprofen for mild fever and discomforts  Topical Creams for itching, sunburn, or insect bites  Benadryl for allergy symptoms  Anti-diarrhea medications for diarrhea  Sudafed for allergy symptoms  Throat Lozenges for couching and/or sore throat

Please list any medication that your child may not take

Open Kitchen coordinator, Pastor, Safety Officer or their representative is authorized to seek any and all emergency health care.

My Child and/or I, have permission to take part in all church/youth activities under supervision unless limitations are noted, and I agree that the church and it’s personnel will not be held responsible for accident arising there from. I hereby give permission to the church to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering X-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I either have appropriate insurance or, in it’s absence, agree to pay all the costs of medical services as may be incurred on myself or my child’s behalf.

Parent Signature Date