Youth Ministry Parental Consent & Release Form

Youth Ministry Parental Consent & Release Form

It is only necessary to complete this form once unless you have changes to your insurance or the language is revised. This form expires when your student graduates out of youth ministry Please contact Chad with any updates. (one student per form)
PARENT/GUARDIAN INFORMATION
Mother's Name*

First NameLast Name
Mother's Number
Please enter a valid phone number.
Mother's Email
example@example.com
Father's Name

First NameLast Name
Father's Number
Please enter a valid phone number.
Father's Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY CONTACT PERSON
Emergency Contact #1*

First NameLast Name
Emergency Contact #1 Phone*
Please enter a valid phone number.
Relationship to Student*
Emergency Contact #2

First NameLast Name
Relationship to Student*
Please type I UNDERSTAND in the text box below:*
I UNDERSTAND
TRANSPORTATION

Please list all students in your household who have your permission to ride in North Summit Church vehicles.*

	Name	Date of Birth
1)
2)
3)
4)
5)
6)

PHYSICIAN AND INSURANCE
Name of Physician*
Physician's Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physician's Office Phone*
Please enter a valid phone number.
Insurance Information
Insurance Company Name
Insurance Policy Number
Name of Insured
Attach a copy of both sides of your insurance card

Take a picture of the front and back of your insurance card and upload it here. If you have a scanner that works too!
Cancelof
Health Information
Known Allergies*
If none, type none
List any medication or drugs taken regularly*
If none, type none
Date of last tetanus shot*

MonthDayYear
Date

Assumption of risk, waiver, medical release, photography authorization, and permission to attend activities
By signing this form, as the parent(s) or legal guardian(s) of*

First NameLast Name
Liability Release

I hereby grant my permission for my son/daughter ("youth") to attend the activities sponsored by the Youth Ministries of North Summit Church in Sandpoint, Idaho ("NSC Youth Activities"). I understand these NSC Youth Activities will be coordinated by adult volunteer and/or staff members of the NSC Youth Ministries and I have been informed (or have had the opportunity to be informed) about the nature and type of the activities that the Youth will engage in during the NSC Youth Activities. I hereby represent that the Youth is capable of physically participating in the NSC Youth Activities and I am not aware of any medical or other reason why the Youth's participation in the NSC Youth Activities would pose a danger to himself/herself or others. I acknowledge that the NSC Youth Activities are part of the charitable mission of North Summit Church and that I and the Youth are beneficiaries of these activities. I understand the risks involved in the NSC Youth Activities include injury including, but not limited to, the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. I have explained the type of activities and the risks involved in the NSC Youth Activities to the Youth and he or she wishes to participate. As consideration for allowing the Youth to participate in the NSC Youth Activity, I hereby assume all risks related in any way to the Youth's involvement in the NSC Youth Activities, known or unknown, to the fullest extent permitted by the law and do hereby release and give up (on behalf of myself and the Youth) any and all claims for damages caused in any injury to the Youth whatsoever as a result of the Youth's participation in the NSC Youth Activities.

I AGREE TO HOLD NORTH SUMMIT CHURCH, IT'S STAFF AND/OR VOLUNTEERS, THEIR RESPECTIVE SUCCESSORS AND ASSIGNEES HARMLESS AND TO INDEMNIFY THEM TO THE FULLEST EXTENT PERMITTED BY THE LAW FROM ALL DAMAGES AND EXPENSES INCLUDING WITHOUT LIMITATION ATTORNEYS FEES INCURRED THAT ARE IN ANY WAY RELATED TO THE YOUTH'S PARTICIPATION IN THE NSC YOUTH ACTIVITIES, INCLUDING WITHOUT LIMITATION, ANY DAMAGES OR EXPENSES THAT RESULT FROM THE NEGLIGENCE OF FELLOWSHIP BIBLE CHURCH, IT'S STAFF AND/OR VOLUNTEERS.

I also authorize any staff or volunteer of North Summit Church to seek medical treatment for the Youth and hereby authorize medical treatment, including but not limited to emergency surgery or treatment. I will assume the responsibility of all medical expenses incurred for the Youth, if any. This permission shall remain in effect unless revoked in writing and delivered to the Lead Pastor at North Summit Church.

Early Return Home Policy

Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

Photo Release Permission

By signing this document I also acknowledge that my child's photographs may be used in any responsible fashion, by North Summit Church, in its sole discretion, including but not limited to publications, videos, and websites.
Covenant of Community Expectations
Non-Negotiable Rules
- No use of illicit drugs or alcohol
- Presence and full participation in all group activities, including curfews
- No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)
- Smoking and the use of tobacco products are not allowed to, from, or during any trip.
Guidelines for Living in Christian Community
- Adults & youth will be equally responsible for performing assigned tasks in a timely manner.
- Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times.
- Participants will be respectful of both common living spaces and the property of others.
- Participants will avoid the use of foul language, cursing, or any speech (including “humor) which puts down, makes fun of, or stereotypes other persons or groups.
- Sleeping areas for males and females will be separate.
Youth Participant’s Statement

I pledge to honor God and respect others during activities by following the rules and guidelines printed above. I understand that I cannot participate in activities unless signed.
Student Name*

First NameLast Name
Student Signature*

Clear
Mother's Name*

First NameLast Name
Mother's Signature*

Clear
Date*

MonthDayYear
Date
Father's Name

First NameLast Name
Father's Signature

Clear
Date*

MonthDayYear
Date
Should be Empty:

Youth Ministry Parental Consent & Release Form

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACT PERSON

TRANSPORTATION

PHYSICIAN AND INSURANCE

Insurance Information

Health Information

Assumption of risk, waiver, medical release, photography authorization, and permission to attend activities

Covenant of Community Expectations