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Pastoral Counseling Request

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Full Name (required)

Phone Number

Email Address

Home Address

Age (If under 18)

Have you received any prior counseling?: YesNo

Who referred you to us?

What church do you currently attend?

Are you a member of your church?: YesNo

Appointment & Scheduling
Thank you for taking the time to fill out this information sheet. This will be reviewed by one of the Pastors and the Office Manager will contact you for appointment scheduling. It may take up to one week for the Office Manager to contact you.

Cancellations or Reschedules
If you need to reschedule or cancel an appointment, we ask that you call at least 48 hours in advance. This allows us to reschedule others who are on our waiting list.

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Parental Permission Form

This form is to notify you of activities and events for 2021-2022 and to allow your child to travel with Tampa Covenant Church Youth Group. Permission for your child to participate in specific church field trips may require additional approval during the year.

My Child has my permission to travel on church sponsored trips.

STATEMENT OF PERMISSION AND RELEASE:
I/We, the undersigned, hereby grant the above named student permission to travel with TCC on church sponsored outings. I/We release and hold harmless Tampa Covenant Church, and the pastor or his designees, from all liability for mishap or injury to the student named herein from the time of departure to the time of return. I, individually and on behalf of my child, hereby release, indemnify and hold harmless, Tampa Covenant Church employees, volunteers and agents from any and all actions and claims for personal injury or damages of any kind resulting from the transportation of students by myself or in vehicles owned or leased by me, or from the transportation of my own child to church events and functions in vehicles neither owned nor leased by TCC whether caused in whole or in part by the negligence of TCC, its agents or employees.

TRANSPORTATION PERMISSION:
Depending upon the activity and number of students involved, the transportation may include any of the following: ride in a car driven by an adult; ride in a van driven by an adult or ride in a chartered bus. I give my son/daughter permission to drive/ride in a private vehicle, rental van or public transportation as appropriate for the trip with TCC. In consideration of Tampa Covenant Church’s agreement to allow my child to participate in these trips, I, on my own behalf and on behalf of my child, hereby release TCC and its employees, representatives, officers, agents, teachers, administrators and volunteers from any and all claims, liabilities and damages arising out of or pertaining to any injury that I or my child may sustain as a result of the transportation of my child. I understand that TCC shall not be supervising or monitoring my child’s transportation, and I hereby agree to hold TCC harmless from any and all claims, liabilities and damages pertaining to or otherwise relating to such transportation. By signing below I hereby represent that I am the parent and/or guardian of the child(ren) and that I have authority to sign on my own behalf and on behalf of my child(ren).

AUTHORIZATION FOR EMERGENCY MEDICAL CARE:
In the event my child requires medical/surgical services which require my consent before being supplied and I cannot be reached, I hereby authorize, appoint and empower the church representative to furnish on my behalf such written or oral authorization as may be required. It is understood the best possible care will be given to my child and that the TCC representative(s) will make a conscientious effort to locate the emergency contact(s) listed below before any action will be taken. All medical expenses incurred will be the responsibility of the Participant or the Participant’s family.

Child Medications

Medication Allergies:
Special Conditions:
Current Medications:

Medical Insurance

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Emergency Contacts

Doctor:
Mom:
Dad:
Other:

Phone:
Phone:
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Phone:

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Prayer Request

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“Be anxious for nothing, but in everything by prayer and supplication with thanksgiving let your requests be made known to God.” Philippians 4:6

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Stephen Ministry
In John 15:12, Jesus says, “This is my commandment, that you love one another as I have loved you.” Stephen Ministry is a ministry in which you can bring Jesus’ love and care to those who most need it. If you know someone who is going through a difficult time, contact one of our Stephen Leaders Jayne or Daniel Masters about Stephen Ministry. Our Stephen Ministers are ready to provide focused, confidential, one-to-one Christian care—to help that person experience the healing power of Christ’s love.

I would like to receive prayer updates. Please add my email address (optional):

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