Youth Permission, Medical & Liability Form

Contents

Youth Permission, Medical & Liability Form
Parent/Guardian Contact Information
Emergency Contact Information
Health Care Information
Terms and Conditions

Youth Permission, Medical & Liability Form

Today's Date *

Event Title/Location/Date - You may select more than one event in this field *

Participant Name *

First

Middle

Last

Participant Date of Birth *

Participant Age *

Participant Address *

Address Line 1

Address Line 2

City

State

Zip Code

Participant Mobile Number

Participant Email Address

Parent/Guardian Contact Information

Parent/Guardian Name *

First

Last

Parent/Guardian Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Email Address *

Parent/Guardian Mobile Number *

Parent/Guardian Home Phone Number *

Parent/Guardian Work Phone Number *

Emergency Contact Information

Please provide an alternate point of contact for your minor child.

Emergency Contact Name *

First

Last

Relationship to Participant

Emergency Contact Phone Number *

Emergency Contact Alternate Phone Number

Check this box if you want to add a second Emergency Contact

Add a second emergency contact

Health Care Information

Have you submitted your child's health care information via this form in the last 6 months? *

Has your child's health care information changed in the last 6 months? *

Terms and Conditions

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Wayland Baptist Church Youth Ministry, both on and off church grounds, including the necessary transportation to and from these events and activities. Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the child affected; (3) I cannot be personally contacted.

I further agree not to hold Wayland Baptist Church or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless Wayland Baptist Church for all claims made and liabilities assessed against them as a result of any event or activity. I release Wayland Baptist Church and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity.

Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be returned home due to disciplinary action (when on trips or while on church property), I will be contacted by the leaders and will be responsible to pick up my child and assume the cost of transportation.

Acknowledgement and Acceptance *

By checking this box and typing your name below and clicking the "Submit Form" button, I am signing this Permission, Medical & Liability Release Form electronically. By signing, I agree that I am the parent/guardian of the youth participant mentioned above. I further agree that my electronic signature is the legal equivalent of my manual signature on this agreement. By checking this box and selecting the "Submit Form" button I consent to be legally bound by this Release Form's terms and conditions and acknowledgement and acceptance clause.

Parent/Guardian Signature *

First

Last