Adult Form

TFCA Youth Ministry Adult Emergency Form

Every adult participating in a TFCA Youth Ministry event is asked to have an emergency form on file with up-to-date emergency and health information. Please contact us at studentmin@tfcanglican.org with questions.

Name(Required)

Date of Birth(Required)

Address

Street Address Address Line 2 City State ZIP Code

Cell Phone #

EMERGENCY CONTACT & INSURANCE INFORMATION

Emergency Contact

Relation

Phone

Health Insurance Carrier

Name of Insured

ID #

Group #

MEDICAL INFORMATION

Medications/treatments/inhalers (please list):

Dietary Restrictions (please list):

Allergies to Food or Drugs (please list):

Other Limitations or Restrictions

Additional Health Information/Concerns

AUTHORIZATION FOR EMERGENCY MEDICAL CARE

in the event that no emergency contact can be reached during a medical emergency, I authorize The Falls Church Anglican (also known as "The Church at the Falls – The Falls Church" and TFCA) to serve as my agent for determining the need for authorizing, any diagnosis, treatment, and medical care as is determined by a health care professional to be necessary. Please enter your initials below.(Required)

LEGAL RELEASE

In consideration of The Falls Church Anglican determining the need for, and type of, diagnosis, treatment, or medical care (if any), I hereby release The Falls Church Anglican from any and all liability whatsoever for bodily injuries, property damage, or other claims sustained during or related to Youth Ministry activities. Furthermore, I/we release The Falls Church Anglican from any and all liability whatsoever for bodily injuries or other claims sustained during or related to the diagnosis, treatment, and medical care authorized by The Falls Church Anglican when serving as my agent for determining the need of, and authorizing, such care. I also indemnify The Falls Church Anglican and/or its agents for, and hold The Falls Church Anglican and/ or its agents harmless from, any and all claims or suits brought by any person or entity to the extent of any and all costs, expenses, damages, judgments, verdicts, and/or attorneys’ fees. I have read and I understand the foregoing authorization and legal release. Please enter your initials below.(Required)

This authorization remains in effect as follows (select one):

Until revoked in writing

Until the conclusion of the 2026-27 ministry year

Other

PHOTO POLICY

By completing this permission form, you agree that The Falls Church Anglican may exercise discretion in using pictures and/or video of you and your family from this event for print, website and/or social media communications. If you have any concerns or questions, please contact communications@tfcanglican.org.

ELECTRONIC SIGNATURE

By signing or electronically entering your name in the designated box below, you acknowledge and confirm that you have read, understood, and agree to all the terms and conditions set out above. An electronic signature carries the same legal weight and enforceability as a handwritten signature.

I have read and understand and agree to the foregoing authorization and legal release.

Signature

Date