Diagnosis: Please check all that apply & select degree of severity:
Medication/Medical Information:
**If you have a medical plan of care for emergencies, please attach a copy. The same plan that you have for school or daycare provider is acceptable.
Parent & contact information
***Please update this plan of care yearly or if any significant changes occur in your child’s (children’s) status.
By submitting this form and registering your child for an event at Liberty Church Marietta, you are agreeing to allow Liberty Church Marietta to take photos of your child to be used in future publications for Liberty Church Marietta. I also understand that the program has activities that can possibly involve physical contact with other participants, the ground or equipment, and understand there is a small risk of injuries. I therefore release and discharge all liability for any harm suffered due to my child's participation in the program. I give permission to the staff and volunteers to administer first aid or seek medical care for my child during my child's attendance, if necessary.