Kids Church Registration

HEALTH DISCLOSURE AND AUTHORIZATION

As parents/guardians for the child or children named below, we provide this Health Disclosure and Authorization in connection with our child or children named below being allowed to participate in the NJV Kids Church Ministry and Activities of the North Jersey Vineyard Church. This form is in addition to the Waiver and Release of Liability executed by the undersigned and does not supersede or alter any provisions of that agreement. It is understood the information herein will remain confidential and reviewed only by church authorities, or if required, appropriate health officials. As the parents named below, we state as follows:

1. To our knowledge, the child/children identified below have not been diagnosed or treated for COVID-19 or any related conditions recognized by the CDC. If that changes, we will notify the church immediately and remove our child/children from all church programs and activities.

2. As the parents/guardians of the undersigned child/children, we nor anyone in our household, have not been treated or diagnosed with COVID-19 or any related conditions recognized by the CDC. If that changes, we will notify the church immediately and remove our child/children from all church programs and activities. In such event, we will seek guidance from the church as to whether we or any other members of the household may continue to participate in church activities until further notice.

3. We are not aware of any contact the child/children named below have had with anyone who has been treated or diagnosed with COVID-19 or any related conditions recognized by the CDC. If that changes, we will notify the church immediately.

4. Neither our child/children identified below, or anyone else in our household, have traveled to or from any of the areas listed in the Warning Levels as defined by the CDC. The undersigned understand the church is requiring parents to execute this Health Disclosure and Authorization and a separate Waiver and Release in an effort to protect all children who participate in the NJV Kids Church Ministry and activities within the church as well as church staff. We understand the importance of this Disclosure and of our obligation to disclose any changes in the future required herein.

5. We authorize the above individuals associated with the church to make any disclosures of health information disclosed pursuant to this Health Disclosure and Authorization or the separate Waiver and Release of Liability that is or may in the future be required by applicable laws, regulations, or health guidelines.