MOSAIC YOUTH CONSENT FORM

MOSAIC YOUTH CONSENT FORM

Annual Lock-In
Student's Full Name*

First NameLast Name
Birth date*

MonthDayYear
Date
Grade*
Student's Phone Number (if applicable)
Parent #1 Name & Phone Number*

NamePhone Number
Parent #2 Name & Phone Number*

NamePhone Number
Parent Email
example@example.com
Student's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional contact if parents cannot be reached*
Name
Relationship to student
Phone Number*
Format: (000) 000-0000.
Medical Information:
Allergies/Medical Conditions/Medications that we need to be aware of*
Consent & Permission for Treatment:
I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to my child participating in the Mosaic Youth lock-in and trip to The Edge in Belleville, IL, which includes bus transportation to/from The Edge on January 3-4, 2025.

I, as parent or legal guardian of the child listed above, believe that the necessary precautions and plans for the care and supervision of the students during this trip will be taken. In case of an emergency, I understand that the youth leaders of Mosaic Church will make every effort to contact myself or an adult listed above. In the event that none of the above can be reached, I hereby give my permission to the licensed healthcare provider selected by Mosaic Church leadership to secure proper treatment, including related transportation, hospitalization, anesthesia, surgery, or medication for my child. I do, hereby, release Mosaic Church and all volunteers associated with this youth trip from any and all claims, loss, cost, damage, liability, or expense arising out of or from any accident or other occurrences causing injury to any person or property.
Signature of Parent or Guardian
Signature
Date

MonthDayYear
Date
* Don't forget to also click the registration fee link so we can officially add you to the list! :)
Should be Empty:

MOSAIC YOUTH CONSENT FORM

Medical Information:

Consent & Permission for Treatment:

* Don't forget to also click the registration fee link so we can officially add you to the list! :)