United Youth Authorization & Consent Form - School Year 2022-23
Information received is confidential and is being gathered for the purposes of serving your child while in the care of PDAC. Any medical information collected here serves to authorize PDAC, and its staff and volunteers, to obtain medical assistance in emergencies.
Student Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Grade in September
*
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Graduated High School
Health Card Number
*
Student Email
(Not required. By giving this email, you're granting permission for youth leaders to email your child)
Student Cell Phone
-
Area Code
Phone Number (Not required. By giving this number, you're giving permission for youth leaders to text and/or call your child)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies
Does your child have any physical, emotional, mental, behavioral concerns or limitations we should be aware of? If yes, please explain
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number (choose the best number to contact you in an emergency)
*
-
Area Code
Phone Number
Parent/Guardian 2 Name
First Name
Last Name
Parent/Guardian 2 Phone Number
-
Area Code
Phone Number
In the event of an emergency and I can't reach you at the number(s) listed above, who is another person we could contact (include name and phone number)?
*
Parent/Guardian Email
*
example@example.com
Sign Up this email for United updates and information
*
Yes
No
Parent/Guardian 2 Email
example@example.com
Sign Up this email for United updates and information
Yes
No
Do youth leaders have permission to contact your child on social media? (For example, there's an Instagram group chat)
*
Yes
No
Do you grant permission for the reasonable use of photos of your child? (They will never be labeled or identified with their names)
*
Yes
No
Do you grant permission for one on one mentoring of your child by a youth leader? (Done in a public place such as a coffee shop)
*
Yes
No
This year, we intend for United to be in-person. However, if government regulations change, we may have to move online. This form is intended to cover both of these possibilities. Therefore, by signing this form you are giving permission for your child to join online group video chats through zoom. I, the parent or guardian named above, authorize Youth Leaders or one of the Pastoral Church Ministry Staff to sign a consent form for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment or procedures for the participant named above. I, named above, undertake and agree to indemnify and hold blameless the Ministry Staff, of PDAC, its Pastors and Board of Elders from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of the PDAC, as well as of any medical treatment authorized by the supervising individuals representing the church. This consent and authorization is effective only when participating in or traveling to events of PDAC.
*
Clear
Submit
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