I am the parent/legal guardian of the above-referenced minor child (“my minor child”). By signing this consent form, I am providing my express consent for my minor child to participate in a Signal Mountain Presbyterian Church (“SMPC”) activity, which will take place away from SMPC property. This authorization shall cover this activity and travel to and from this activity.

I understand and acknowledge that, to the extent SMPC employees and/or volunteer workers are transporting my minor child to such activity, there are risks inherent in such transportation. I further understand and acknowledge that my minor child may be participating in physical games and activities which carry inherent risks, and which could potentially result in injury. I am providing my informed consent with knowledge of these facts.

I hereby authorize and give my power of attorney to the adult SMPC employees/volunteer workers who are supervising the above-referenced SMPC activity to act as my agent to consent to all necessary and appropriate emergency health care services for my minor child, including, without limitation, emergency transportation, examination, diagnostic tools (x-ray, etc.), anesthesia, injection, medication, surgery, medical treatment, dental treatment, and/or hospital care as advised and administered by a health care provider licensed to practice under the laws of the state where the services are rendered, including, without limitation, physicians, dentists, and nurses. I therefore assume all responsibility for such decisions and the emergency care or treatment secured for my minor child. I understand that every attempt will be made to contact me as parent or guardian in the event of an emergency involving my minor child. To that end, I am providing contact information (in the space provided above) where I can be reached during the SMPC activity in which my minor child will be participating. I also understand that some hospitals/health care providers require health care information and a notarized authorization before health care services will be rendered to a minor child. For that reason, I am being given an opportunity to provide my health insurance information above.

Finally, to the extent that my minor child has any specific allergies or special physical or psychological needs and/or limitations or is taking any medications of which the SMPC employees/volunteer workers supervising my minor child’s activity should be aware, I hereby agree to list them above or on an attached sheet and to discuss such issues, if necessary, with such SMPC employees/volunteer workers.

I understand that during this event, agents of SMPC may photograph, film, or record my child and that these images and/or recordings may be used in presentations or promotions for SMPC, including the website without any payment to my minor child or his/her family.  Questions or reservations shall be addressed to any SMPC employee responsible for organizing and/or supervising this event.

I am aware of COVID-19 and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19. I am further aware of other pertinent governmental orders, directives and guidelines (collectively, “directives”), relative to COVID-19 and have instructed my child on the same, including directives for frequent handwashing, social distancing and use of face masks in public locations. I am aware that some of the planned activities will occur in a public location during the COVID-19 pandemic, or involve situations where social distancing is not practical, and are therefore potentially hazardous activities. I am aware that my minor child could be infected, seriously injured or even die due to COVID-19. I am also aware that as a result my child might infect me or other members or my family. I understand the hazards of COVID-19 infection and I acknowledge and understand that that the circumstances regarding COVID-19 are changing from day to day and that, accordingly, the CDC guidelines are regularly modified and updated, and I accept full responsibility for familiarizing myself with the most recent updates.

I again state that in consideration of the benefits to be derived, and after carefully considering the risks involved, I, for myself and on behalf of my minor child, heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS, to the fullest extent of the law, SMPC, its officers, leaders, agents, volunteers and members WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE OF PERSON OR PROPERTY regarding my minor child and/or arising from his/.her activities or participation in this event.