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Youth Activity Consent Form
Youth Activity Consent Form
Jason Chelf
2020-12-30T13:16:03-05:00
Name of Youth
*
First
Last
Birthday
*
MM slash DD slash YYYY
Name of Parent or Guardian
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
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Tennessee
Texas
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U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home or Cell Number
*
Work Number
*
Other person to contact in an emergency
*
First
Last
Other person's Number
*
Consent and Certification
I, the undersigned, being the parent or legal guardian of the youth named above,
To the participation of my youth in all the scheduled youth activities of The Point, Crave Student Ministries and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.
*
Do hereby consent:
To the participation of my youth in all the scheduled youth activities of The Point, Crave Student Ministries and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.
Note to Parent: If giving consent for one activity only, or if this consent is otherwise restricted, please specify:
Medical Treatment Authorization
*
I Understand:
That I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth, if required by law or a health care provider:
Pastor Tim Cox, or another adult chaperone designated by the The Point, and:
(Note to Parent: you may add or delete a name as desired.)
*
I Authorize:
These persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care.
Furthermore
*
I Understand:
That The Point, its staff, and volunteers will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the youth director in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the youth leader and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth.
NameSignature of Parent or Guardian
*
First
Last
Date of parent signature
*
MM slash DD slash YYYY
Youth Pledge
*
I hereby pledge:
To uphold all policies of Crave Student Ministries. During all youth activities and all youth trips, I pledge to follow all instructions of the youth leader and the adult chaperones, including safety instructions.
Signature of Youth
*
First
Last
Date of Youth Signature
*
MM slash DD slash YYYY
Medical Information
Is your youth presently being treated for an injury or sickness or taking any medication?
*
Yes
No
If YES, please explain:
Does your youth have, or has your youth ever had, any of the following?
*
Asthma
Hay Fever
Kidney Disease
Diabetes
Heart Murmur
Seizure Disorder
Other
If other, please explain:
Does your youth ever sleepwalk?
*
Yes
No
Youth's blood type:
*
Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?
*
Yes
No
If yes, please explain:
Family Doctor
*
First
Last
Family Doctor's Phone Number
*
Insurance Company
*
Insurance Policy Number
Email
This field is for validation purposes and should be left unchanged.
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