2022-2023 Youth Group Registration and Consent Form

Youth Information

Youth's Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade Entering*

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Permission to e-mail or text youth directly*

YesNo

Youth E-mail

example@example.com

Youth Cell Phone

Area CodePhone Number

Parent/Guardian Information

1st Guardian's Name*

First NameLast Name

2nd Guardian's Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number*

Area CodePhone Number

Alt. Cell Number

Area CodePhone Number

E-mail*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Health Insurance Information

Is your child covered by health insurance?*

YesNo

Insurance Provider*

Policy #*

Name or Insured*

Relationship to Youth*

Insured's Date of Birth

Insured's Date of Birth*

Date

Copy of Insurance Card (Front and Back)

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Youth Health History

Does the youth have any allergies, chronic illness, or medical conditions? If yes, please describe.*

Is the yout prescribed an medications? If yes, please provide medicine name, dosage, and explain any instructions.*

Please list any over the counter medicines than cannot be administered to your child.*

Please list any limitations we should be aware of.*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s attendance and participation in any and all activities sponsored by LakeShore Presbyterian Church from September 2022 - August 2023 including the selected summer camp. In exchange for the acceptance of said child’s candidacy by LakeShore Presbyterian Church. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless LakeShore Presbyterian Church, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of moderate and severe personal injury, property damage, disability, death, and sickness or disease including, without limitation, COVID-19 to said child, I hereby waive all claims against LakeShore Presbyterian Church including all counselors and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured or contracting a communicable disease that is inherent in all camp activities in including but not limited to waterfront activities, giant slip n slide, and ziplining. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As Parent and/or Guardian of the named youth, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named youth. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to LakeShore Presyterian Church and its affiliates including Youth Leaders, Directors and Camp Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized for September 2022 - August 2023 (including summer camp).

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Above Medical Authorization Granted*

YES, I give permission for the church leaders or other qualified personnel to seek or administer medical treatment to my child.NO, I do not give permission for anyone to seek or administer medical treatment to my child. (If this option is selected an emergency contact must be listed above.)

Photo Release

LakeShore Presbyterian Church has my permission to use my or my child’s photograph publically to promote the Church. I understand that the images may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such of such use.

Photo Release is valid for September 2022 - August 2023.

Permission to use photos*

YesNo

Changes/Updates

If at anytime the above information changes, please notify the youth leaders and complete a new registration form for the file.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

Date*

Date