Youth Activity Consent Form

Name of Youth*

First Last

Birthday*

Name of Parent or Guardian*

First Last

Address*

Street Address Address Line 2 City 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,

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*

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*

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

Comments

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