Overflow Application

FAMILY INFORMATION
CHILDREN WITH SPECIAL NEEDS:
SIBLINGS
IN CASE OF AN EMERGENCY, THE FOLLOWING PERSONS MAY BE CALLED AND ARE AUTHORIZED TO PICK UP MY CHILD: (AT LEAST ONE CONTACT MUST BE PROVIDED. Positive identification MUST be provided before your child will be released)
SERVICES CURRENTLY BEING RECEIVED
SCHOOL OR PROGRAM YOUR TEEN IS ATTENDING:
Permission and Authorization Agreement
I have fully disclosed to Custer Road United Methodist Church all pertinent facts about my child(ren)'s special needs and accept full responsibility for failure to do so.
I understand that care for all children will be provided by trained volunteers. I understand that medications and treatments cannot be administered by volunteers or any respite staff.
In case of an emergency or accident, I understand that the Plano EMS (911) will be called. I authorize EMS to administer any medical treatment, medication or appliance deemed necessary by EMS. I also authorize transportation by EMS to the nearest appropriate medical facility, as determined by EMS. I understand that I will be responsible for payment of all EMS, hospital, and physician charges for emergency services to my child.
I have read and initialed the above permission/authorization statements and agree to the terms designated in each.
V. PUBLICITY RELEASE
Pictures and film may be taken at OVERFLOW for the purposes of publicity, pictorial recordings and identification.
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