THE AFM OF SOUTH AFRICA
ROCK FOUNDATION
Emails: afmrockfounation1@gmail.com,rgmasingi@gmail.com
BUILDING TOGETHER WITH CHRIST ON HIM THE ROCK
MATTHEW 7:24, Luke 6:48, 1 Corinthians 3:9-11
CONSENT FORM
Parental/Guardian Consent Form and Liability Waiver
Participant's / Child's Name:______________________________Birth Date:_______________
Parent/Guardian's Name:__________________________________________________________
Home Address:____________________________________________________________________
Home Phone :_____________________________Work Phone: __________________________
I, (Parent/Guardian)___________________________________grant permission for my child,
(Child s Name)______________________________________to participate in this Youth trip
event that requires transportation. This activity will take place under the guidance
and direction of youth leadership and/or volunteers from AFM ROCK.
A brief description of the activity follows:
Type of event____________________________________________________
Location of event: _______________________________________________
Individual(s) incharge:_____________________________________________________________
Date and time of departure:_________________________return_________________________
Mode of transportation to and from event:_________________________________________
On behalf of myself /as parent and/or legal guardian, I remain legally responsible for
any personal actions taken by the above named or participant. In granting this
permission, I assume full responsibility for and damage to a person/property caused
by the above participants. Further, I hereby expressly waive any claim for liability
against the Organization , including its representatives, and release them from any
liability in connection with this trip. I expressly agree that in the event that
disciplinary action or the health of the above participant , may make it necessary the
participant may returned home at my expense. I consent and will be responsible for
any medical or dental treatment, which may be advisable at the discretion of any
physician or dentist during the trip. It is further warranted that if one parent or
guardian signs this Parent Consent Form, it is with the authority of the other.
Signature___________________________ Date:_________________________
MEDICAL MATTERS
I hereby warrant that to the best of my knowledge, my child is in good health, and I
assume all responsibility for the health of my child.
Emergency Medical Treatment:
In the event of an emergency, I hereby give permission to transport my child to a
hospital for emergency medical or surgical treatment. I wish to be advised prior to
any further treatment by the hospital or doctor. In the event of an emergency and
you are unable to reach me at the above numbers, contact
Name: __________________________________________________________________
Relationship: ___________________________Phone:__________________________
Family Doctor:__________________________Phone:_________________________
Specific Medical Information: The Organizer will take reasonable care to see that
the following information will be held in confidence:
Allergic reactions (medications, foods, plants, insects, etc.):_________________________
Does child have a medically prescribed diet? ______________________________________
Any physical limitations?___________________________________________________________
Is child subject to chronic homesickness, emotional reactions to new situations,
sleepwalking, fainting? ____________________________________________________________
Has child recently been exposed to contagious disease or conditions,
such as mumps, measles, chickenpox, etc.? If so, date and disease or
condition:________________________________________________
You should be aware of these special medical conditions of my child:
