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Claremont Presbyterian Church

Parental Consent for Medical Treatment and Permission for Youth 2012-2013
Youth's Name___________________________Home Telephone No.___________________________
Street Address______________________________________________________________________
Age______ Gender_______ Social Security Number_______________________________________
Parent/Guardian Name_______________________________________________________________
Parent/Guardian Work Telephone No.____________________________________________________
Medical Insurance Co.________________________________________________________________
Policy Number_________________________Member's Name_______________________________
Medication (amount and frequency taken)
Physical Handicaps or Limitations
I hereby release Claremont Presbyterian Church, its staff and adult representatives from
responsibility and liability for any injury or illness that my child may sustain during an event. In
the event of an emergency, I hereby authorize an adult leader of this activity, as agent for me, to
consent to any X-ray examination, medical, dental, or surgical diagnosis; treatment; and
hospital care advised and supervised by a physician, surgeon or dentist (as appropriate)
licensed to practice under the laws of the state where services are rendered, either at a doctor's
office or in any hospital. I expect to be contacted as soon as possible.
Parent or Guardian
If parent or guardian are not available, please call the relative listed.
Name________________________________________________Telephone No._________________

I hereby agree to wear my seatbelt at all times when riding in a church accompanied vehicle. If I am
found riding without my seatbelt fastened, my parents will be contacted to pick me up immediately.
Signature of Youth_________________________________________________________________
I understand that my child is responsible for wearing his/her seatbelt at all times while in a church
accompanied vehicle. If he/she is found not wearing a seatbelt, I understand that I will be contacted to
pick up my child immediately.
Signature of Parent or Guardian_______________________________________________________
Much of what happens at Claremont Presbyterian Church's youth events will be shared online in the
form of photos and videos posted to a blog (, Facebook, Twitter, YouTube, or
Flickr. As a rule, youth are identified by their first name only. This sharing allows people outside of
the church's youth programs to participate in our life together, from youth's friends and families to
church members who don't have youth in the programs.
However, privacy is respected. If a youth or their parent/guardian does not wish to have a youth's image
shared online they may exempt that youth by signing below. By so doing, the youth or parent are
guaranteeing that no pictures or videos of the youth will be shared by staff or volunteers of Claremont
Presbyterian Church.
By signing below I am denying permission for pictures or videos of ___________________________
to be shared online in any form by any staff or volunteer of Claremont Presbyterian Church.
Signature of Youth


Signature of Parent