MINT First-Time Information Sheet

We're so excited to have you with us! Before you come for your first visit, please be sure to fill out and submit this form.

First Name

Last Name

Email

Phone Number

How Many Children Will You Have Attending With You?

Child 1 First Name

Child 1 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 2 First Name

Child 2 Last Name

Gender

Kid 2 Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 3 First Name

Child 3 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 4 First Name

Child 4 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 5 First Name

Child 5 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 6 First Name

Child 6 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 7 First Name

Child 7 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 8 First Name

Child 8 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 9 First Name

Child 9 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Child 10 First Name

Child 10 Last Name

Gender

Birthdate

Allergies

Please List Any Persistent Medical Problems (i.e. asthma, epilepsy, heart condition, diabetes, disability, etc.)

Please List Any Medication This Child Is Currently Taking

Are There Any Acitivies Your Child Should Not Participate In? If So, Please Explain.

Release Form

I, the undersigned, as the parent or legal guardian of the child(ren) named above, do hereby give my full consent and approval for my child(ren) to attend events at the Hardin Valley Church of Christ, 11515 Hardin Valley Road
Knoxville TN, 37932.

I also grant permission for my child(ren) to use the facilities and equipment located on the property of the church, including but not limited to the playground and recreational equipment. I understand there are always certain risks of damages and personal injuries inherent in the use of such facilities and equipment. I am willing to assume these risks on behalf of my child(ren). These risks include but are not limited to, those hazards associated with other participants and the equipment itself. Further, I agree that as consideration for the church allowing my child(ren) to have access to the facilities on church property and to use the playground and recreational equipment:

1. On behalf of my child(ren) and myself, I do voluntarily elect to accept and soley assume all risk of injury incurred or suffered by my child(ren) while on the church property and

2. In addition to giving my full consent for my child's participation, I do hereby wave, release, discharge and agree to indemnify and hold harmless the Hardin Valley Church of Christ, it's elders, deacons, ministry leaders, employees, members, and volunteers not to sue the church, its officer, staff,
employees, or volunteers for any claim, damage, costs, including attorney fees, or cause of action which I, or my child(ren) have or may have in the future as a result of damages, injuries sustained or incurred by my child .

I further agree on behalf of myself and my child(ren) listed, that I shall hold harmless and fully indemnify the partied hereby released from any and all claims, damages, costs, including attorney fees, and causes of action which
may arise from any cause of action made by me or by, through or on behalf of my child(ren), even if the damages, injuries or death are caused in whole or in part by any of the persons or entities hereby released.

CHILDREN ARE NOT TO BE DROPPED OFF OR LEFT AT THE BUILDING WITHOUT PARENTS / GUARDIANS PRESENT AT ANY TIME!

I acknowledge that I have (a) read, (or have had read to me) each and every one of the provisions in this waiver, release of liability, and indemnification agreement, (b) that I understand each of the provisions in the agreement and (c) that I agree to abide them.

Signature