Youth Consent Form – Arbuckle Community Church

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Student Information

Student Name *

First

Last

May we contact your student directly?

Yes
No

Medical Information

Is your student presently being treated for an injury/sickness or taking any medication? *

Yes
No

Does your student sleepwalk? *

Yes
No

Does your student have a physical handicap/illness that would prevent him/her from participating in normal rigorous activity? *

Yes
No

Family Doctor/Clinic *

Doctor/Clinic Phone *

Insurance Company *

Policy Number *

Consent and Certification

I, the undersigned, being a parent or legal guardian of the student named above, do hereby consent to the participation of my student in all the scheduled activities of Arbuckle Community Church, and any other supervised activities customarily associated with its Arbuckle Youth or Arbuckle Kids, including youth group and overnight or weekend youth trips. Further, I certify that my student, unless noted above, is physically fit and adequately prepared to participate in all recreational and sporting events, unless noted in the medical section. If I wish to revoke this consent for any reason, I will promptly notify a church leader in writing.

This consent is for

The year of 2022
Indefinite
For a single event

Medical Treatment Authorization and Release of Liability

This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability against personal losses of named student.

I/We have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from all liability for any injury, loss, or damage to person or property that may occur during my/our child’s involvement. If he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent.

I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by a family ministries staff member.

I have read and agree to the above statment *

Yes