Parental Consent, Certification, and Medical Authorization
Parents and legal guardians of minor children (under age 18) are asked to complete this form and return itto the church. The information requested is designed to assist the church in providing for the safety of minors during church sponsored activities.
GENERAL INFORMATION (please print)
Youth’s Name___________________________________________Date of Birth___________________ Father’s Name___________________________________Mother’s Name_________________________ Youth’s Address_______________________________________________________________________ Home Phone No.__________________________________Parent’s Work Phone No.________________ Emergency Phone No._______________________________ Family Doctor_____________________________________Phone No.___________________________ Health Insurance Plan/Number____________________________________________________________
GENERAL RELEASE/HOLD HARMLESS AGREEMENT
As the parent or legal guardian of the above student, I agree to the following:
1. DESIRE-
The student above desires to participate in the program, events, or activities (hereinafter collectively referred to as “activities”) operated or sponsored by The Bible Fellowship Church of Royersford (hereinafter referred to as the “Church”) and its youth ministry.
2. POSSIBILITY OF INJURY
– The student above may incur personal injury or bodily damage while participating in such Activities.
3. NECESSITY OF PERMISSION FORM -
The student above cannot participate in such Activitieswithout releasing and holding harmless the Church and the youth ministry.
4. GENERAL RELEASE AND DISCHARGE –
I, the undersigned, request that the Church and itsyouth ministry allow the student to participate in the Activities and in consideration thereof agree tohereby release, and forever discharge the Church, its youth ministry, the youth director, its officers, andany parties volunteering on behalf of the Church or its youth ministry from all action, claims, damages,costs, expenses, or damages of any kind growing out of or related to the Activities.
5. RELEASE FOR INJURY AND DAMAGES -
I acknowledge that this is a full and complete releasefor all injuries and damages which the student may sustain as a result of participating in the Activities.
6. TREATMENT FOR INJURY –
I authorize the treatment of the student by a qualified and licensedmedical doctor in the event of a medical emergency which, in the opinion of the attending physician, mayendanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, whilesaid minor is participating in the Activities, including transportation to and from the site. This authority isgranted only after a reasonable attempt has been made to contact me, the parent/guardian. I understandthat the Church will not be responsible for medical expenses incurred, but that such expenses will be myresponsibility as parent/guardian.
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