Parental Consent

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					           Northern Missouri District Youth – Student AIM Application Consent Forms
                          2600 I-70 Drive North West Columbia, Missouri 65202
                                  Nicaragua – July 19 – 27, 2012

                             Parental Consent Forms
Parents and legal guardians of minor children must complete these documents and return them to the
Northern Missouri District Office. Please included these completed documents with your student’s
completed application. The information that is requested below is designed to assist your church, the
Northern Missouri District Office and the leadership team in providing for the safety of minors during
church and district sponsored activities.



Student Information
Your Child’s Name: _____________________________________________________________________

Primary Address: _______________________________________________________________________

City: ________________________________________ State: ___________               Zip Code: ___________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________

Date of Birth: ___________________________________             Age: ______      T-Shirt Size: _________

Place of Birth (city, state, country): ________________________________________________________



With whom does your child reside with? ____________________________________________________

Who is the child’s primary guardian? _______________________________________________________



Your Child’s Primary Care Physician’s Name: _________________________________________________

Office Address: ________________________________________________________________________

City: ________________________________________ State: ___________               Zip Code: ___________

Telephone: _(_____)_______________________             Alternate Phone: _(_____)_________________



Your Child’s Health Insurance Company: ____________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________               Zip Code: ___________

Policy Number: ___________________________             Telephone: _(_____)______________________




Aug 2011                                                                                    Page 1 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                         2600 I-70 Drive North West Columbia, Missouri 65202
                                 Nicaragua – July 19 – 27, 2012

Family Information
Child’s Parent or Guardian’s Name: ________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________


Child’s Parent or Guardian’s Name: ________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________


Child’s Step Parent’s Name: ____________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________


Child’s Step Parent’s Name: ___________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________

Aug 2011                                                                                  Page 2 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                          2600 I-70 Drive North West Columbia, Missouri 65202
                                   Nicaragua – July 19 – 27, 2012

Health Information
Is your child in good physical health? If no, please explain. ____________________________________

_____________________________________________________________________________________

Does your child have any physical handicaps? If yes, please explain. _____________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Does your child have any physical condition or illness which would prevent him or her from participating
in normal, rigorous activities such as swimming or running? If yes, please explain. __________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Can your child swim? ___________________________________________________________________

Has your child ever walked in their sleep? If yes, please explain. ________________________________

_____________________________________________________________________________________

Does your child medically require a special diet? If yes, please explain. ___________________________

_____________________________________________________________________________________



Medical History
Does your child have any known allergies to food or insects or the environment? If yes, please explain.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Does your child have any known allergies to medications? If yes, please explain. ___________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________


Aug 2011                                                                                     Page 3 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                           2600 I-70 Drive North West Columbia, Missouri 65202
                                    Nicaragua – July 19 – 27, 2012

Does your child have, or ever had, any pertinent medical history such as a seizure disorder, a heart
condition, asthma, depression, kidney disease, heart problems, or any other diagnosis? Is your child
presently being treated for any injury or sickness or illness? Please list all information below. Please
understand that all information is confidential but is required for emergency medical interventions.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Is your child taking any prescribed medications? If so, please list all prescribed medications and over the
counter medications that your student will bring with them this outreach mission. Please know that all
information is confidential but is required for emergency medical interventions. Any medications that
you will bring on this mission must not be expired and must be in the prescribed packaging or bottle.
This would be a good time to renew prescriptions such as inhalers and epi-pens.

Medication                      Dosage / Frequency               Purpose

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________

_____________________           ____________________             ________________________________



Aug 2011                                                                                       Page 4 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                          2600 I-70 Drive North West Columbia, Missouri 65202
                                   Nicaragua – July 19 – 27, 2012

Medical Treatment and Authorization Form
I (parent or guardian) __________________________________________________________________,

the parent or guardian of (your child’s name) _______________________________________________,
also known as the undersigned, being the parent or legal guardian of the child named above, do herby
understand that I will be notified in the case of a medical emergency involving my child in the most
timely manner based on the emergency contact information listed below. However, in the event that
either parent or guardian cannot be reached, I authorize the calling of a physician and the providing of
necessary medical services and interventions needed in the event our child is injured or becomes ill. I
authorize any adult leader participating on this NOMO AIM Outreach or any Assemblies of God
Missionary to make emergency medical care decisions on the behalf of my child, if required by law or a
health care provider. I understand that the Assemblies of God National Youth AIM Office and the
Northern Missouri District Office or any of their agents, employees, or volunteers, will not be
responsible for medical expenses incurred on the basis of this authorization.

I also agree to notify the leadership of this NOMO Youth AIM Outreach in the event of any health
changes which would restrict our student’s participation in any outreach activities. I also understand
that the adult NOMO Youth AIM leadership and representatives reserve the right to restrict our student
from any activity that they do not feel is within the physical capabilities of our child.

I verify that I am the parent or guardian of the minor named above and have the legal authority to
execute the above release. I have read this release and fully understand its contents. I approve the
foregoing and waive any rights in the premises.

Parent or Guardian Signature: _____________________________________             Date: ______________



Emergency Contact Informaiton
Child’s Parent or Guardian Name: _________________________________________________________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________

Child’s Parent or Guardian Name: _________________________________________________________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________

Emergency Contact Name & Relationship: __________________________________________________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________

Emergency Contact Name & Relationship: __________________________________________________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________

Emergency Contact Name & Relationship: __________________________________________________

Telephone: _(_____)_______________________             Cell Phone: _(_____)______________________


Aug 2011                                                                                     Page 5 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                           2600 I-70 Drive North West Columbia, Missouri 65202
                                    Nicaragua – July 19 – 27, 2012

Consent
I (parent or guardian) __________________________________________________________________,

the parent or guardian of (your child’s name) _______________________________________________,
also known as the undersigned, being the parent or legal guardian of the child named above, do herby
consent to the participation of my child in the above listed NOMO AIM Outreach, including swimming,
boating, hiking, other sporting events, and any other activities customarily associated with an AIM
Outreach. Further, we certify that our child is physically able, and adequately trained, to participate in
such events including swimming.

We do not authorize our child to participate in any of the following activities: ______________________

_____________________________________________________________________________________



I verify that I am the parent or guardian of the minor named above and have the legal authority to
execute the above release. I have read this release and fully understand its contents. I approve the
foregoing and waive any rights in the premises.

Parent or Guardian Signature: _____________________________________              Date: ______________




Model Release
I (parent or guardian) __________________________________________________________________,

the parent or guardian of (your child’s name) _______________________________________________,
also known as the undersigned, being the parent or legal guardian of the child named above, do herby
give the Assemblies of God National Youth Ministries, the General Council of the Assemblies of God, the
Northern Missouri District of the Assemblies of God, and any and all of their licensees and legal
representatives in the irrevocable right to use my child’s name, or any fictional name, picture, portrait,
or photograph in all forms and media and in all manners, including but not limited to, composite or
distorted representations, for advertizing, trade, or any copy, that may be created in connection
therewith.



I verify that I am the parent or guardian of the minor named above and have the legal authority to
execute the above release. I have read this release and fully understand its contents. I approve the
foregoing and waive any rights in the premises.

Parent or Guardian Signature: _____________________________________              Date: ______________




Aug 2011                                                                                      Page 6 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                              2600 I-70 Drive North West Columbia, Missouri 65202
                                        Nicaragua – July 19 – 27, 2012

Insurance Election
I (parent or guardian) __________________________________________________________________,

the parent or guardian of (your child’s name) _______________________________________________,
also known as the undersigned, being the parent or legal guardian of the child named above, do herby
understand the hazards and risks to my child associated with serving in a missions capacity. I further
understand that the Assemblies of God National Youth AIM Office currently requires the insurance
coverage summarized below, that the cost of the insurance is included with the mission trip, that these
coverages are subject to change, and that I am responsible for obtaining any additional insurance
coverage that I consider necessary for my child.

Foreign AIM Outreach Trips – Brotherhood Mutual Insurance Company

        $1,000,000 foreign liability insurance
        $1,000,000 foreign contingent automobile liability insurance
        $1,000,000 employer’s liability
        Foreign worker’s compensation coverage
        Medical accident and sickness coverage ($100,000 / $50,000 / $25,000 / $10,000 as determined by the
         outreach trip leader)
        $250,000 per policy year medical assistance including:
             o Emergency medical evacuation
             o Medically supervised repatriation
             o Repatriation of mortal remains

The above benefits illustrate the highlights of this insurance. The actually policy wording prevails.

Stateside AIM Outreach Trips – Special Markets Insurance Consultants, Inc.

        $10,000 Accident Medical Maximum
        $5,000 Sickness Medical Maximum
        $2500 Accidental Dental and Physical Therapy Maximum
        $25,000 Accidental Death Benefit
        $10,000 Medical Evacuation
        $5,000 Repatriation
        $5000 Return of mortal remains

The above benefits illustrate the highlights of this insurance. The actually policy wording prevails.

Please select one of the following:

    o    I do not desire any additional insurance coverage other than what is currently required as stated
         above.
    o    I do desire additional insurance coverage and will assume full responsibility for obtaining such
         coverage from a private insurance carrier at our expense.

I verify that I am the parent or guardian of the minor named above and have the legal authority to
execute the above release. I have read this release and fully understand its contents. I approve the
foregoing and waive any rights in the premises.

Parent or Guardian Signature: _____________________________________                        Date: ______________

Aug 2011                                                                                                Page 7 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                           2600 I-70 Drive North West Columbia, Missouri 65202
                                    Nicaragua – July 19 – 27, 2012

Parental Consent Authorization for Foreign Travel with a Minor Child
If traveling outside the United States, this original form MUST accompany the traveling minor.

Both parents or legal guardians must sign this document in the presence of a Notary Public.

       If divorced with sole custody, legal documentation from the parent with custody must be
        attached and notarized.
       If a natural parent is deceased, a certified copy f the death certificate is required.
       Step parents cannot sign for a minor unless that child has been legally adopted by that step
        parent, in which case, legal documentation supporting the adoption must be attached and
        notarized.



Consent, Certification and Authorization signatures must be notarized below.
I do hereby grant full authorization and consent for my child, __________________________________,

who is a citizen of the United States of America with a current U.S Passport number of: _____________,

to travel outside the borders of the United States of America with the Assemblies of God Northern
Missouri District Youth. I have approved the travel destinations and dates as listed above. I authorize
Rev. David B. Pafford and Rev. Robert L. Jackson Jr. to make any changes whatsoever to the travel plans
specified above. Under penalty of perjury under the laws of the State of Missouri, I attest to the
truthfulness, accuracy, and validity of the forgoing statements.

With my signature below, I certify that I have honestly and accurately completed all parts of the Parental
Consent Forms (9 pages), and that all of the above information is true, and that I have answered each
question completely and honestly and accurately to the best of my ability.

I further understand that my child’s application will be sent to a screening committee for approval. I
understand that any application fees and other financial requirements, such as once airline tickets are
purchased, are non-refundable.




Aug 2011                                                                                      Page 8 of 9
           Northern Missouri District Youth – Student AIM Application Consent Forms
                         2600 I-70 Drive North West Columbia, Missouri 65202
                                 Nicaragua – July 19 – 27, 2012

Parent or Guardian Notarized Signatures
Child’s Parent or Guardian Name: _________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________

Signature: _______________________________________________            Date: _____________________



Child’s Parent or Guardian Name: _________________________________________________________

Address: _____________________________________________________________________________

City: ________________________________________ State: ___________              Zip Code: ___________

Telephone: _(_____)_______________________            Cell Phone: _(_____)______________________

e-mail: _______________________________________________________________________________

Relationship to the Child: ________________________________________________________________

Signature: _______________________________________________            Date: _____________________




AUTHORIZATION OF NOTARY PUBLIC
IN THE STATE OF: _________________________            IN THE COUNTY OF: ______________________

ON THIS DAY (date): ____________________________________________________________________,

BEFORE ME, ___________________________________________________________, A NOTARY PUBLIC

IN AND FOR ABOVE SAID COUNTY, PERSONALLY APPEARD _____________________________________,

THE SUBSCRIBING WITNESS, KNOWN TO ME TO BE THE PERSON WHO EXECUTED THE WITHIN
AGREEMENT AND ACKNOLEDGED TO ME THAT HE OR SHE EXECUTED THE SAME FOR THE PURPOSES
THEREIN STATED.

NOTARY PUBLIC SIGNATURE: ______________________________________

MY COMMISISON EXPIRES: __________________________             NOTARY STAMP: __________________


Aug 2011                                                                                  Page 9 of 9

				
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