Stayton Christian Church

YFC PR Mission Trip Release Form
Team Name*
Trip Leader's Name*
Dates of Trip
Participant's Full Name*
Name Most Often Called*
Birthdate*

MonthDayYear
Date
Age*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information
Father/Guardian
Phone Number
Please enter a valid phone number.
Address (If different than yours)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother/Guardian
Phone Number
Please enter a valid phone number.
Address (If different than yours)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In case of emergency, if parent/guardian cannot be reached, we will contact emergency contact on next page.

Emergency Contact Information
In an emergency, who should we contact? *

First NameLast Name
Relationship to you (i.e. aunt, grandpa, neighbor)*
Phone Number*
Please enter a valid phone number.

Medical/Health Information
List any current or past serious illnesses, allergies, diseases, etc. (If not, please type N/A)*
Listany known drug/medication allergies
Physician's Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Insurance Company Name
Policy Number

YOUTH FOR CHRIST PUERTO RICO RELEASE OF LIABILITY & CONSENT

TO TREATMENT, TRAVEL & IMAGE RELEASE
RELEASE OF LIABILITY

By signing this form, I acknowledge that participating in YOUTH FOR CHRIST PUERTO RICO activities is a privilege. I understand that there are certain risks of physical injury and/or illness associated with these activities. I understand that there may be other risks associated with these activities of which I may not be presently aware. In consideration of your accepting me or my child for participation in the above-named program, I hereby waive and release any and all right and claims for all losses and damages that I as a parent, or my child may have against YOUTH FOR CHRIST PUERTO RICO and its affiliates, volunteers, agents, employees, representative, successors, and assigns for any and all injuries or losses suffered by me or my child that arise now or in the future as a result of this YOUTH FOR CHRIST PUERTO RICO event.

Further, I agree that in the event that my child or other related person should make any claim in the future against, I indemnify, defend, and hold harmless YOUTH FOR CHRIST PUERTO RICO and its affiliates, volunteers, agents, employees, representatives, successors and assigns against any and all loss and damage, including attorney’s fees, arising directly or indirectly from mine or my child’s actions.

Youth For Christ Puerto Rico activities and events may include but are not exclusive to the following:
- Working alongside local churches & other ministries in Puerto Rico with their staff, leaders, & volunteers
- Traveling to & from various locations on the island to complete ministry & work
- Working on Construction Sites/Work Projects with various tools, machinery, etc.
- Working in neighborhoods/communities for outreach events with families which may involve traveling, physical activities, etc.
CONSENT TO TREATMENT

By signing this form,
I, ___________________________________ as the Parent/Guardian, do
hereby authorize the above references Agent acting as the Participant’s agent,
to consent to any X-ray examination, anesthetic, medical or surgical diagnosis
or other emergency medical treatment and hospital care which is deemed
advisable by, and is rendered under the general or special supervision of any
licensed physician or surgeon; or to consent to an X-ray examination,
anesthetic, dental or surgical diagnosis or emergency treatment to be rendered
to the Participant by any licensed dentist.

It is understood that this authorization is given in advance of any condition which might occur necessitating treatment, but it is given to provide authority and power on the
part of the Agent to give specific consent to any such examination, anesthetic,
diagnosis, treatment or hospital care which the aforementioned surgeon,
physician, medical provider and/or dentist, in the excuse of his/her best
judgement, may deem advisable. It is also understood that since licensing
standards vary between states and nations, the aforementioned surgeon,
physician, medical provider and/or dentist meet only the qualifications
required for licensing in the state or nation in which he/she practices.

I hereby authorize any hospital which has provided treatment to the Participant to surrender physical custody of the Participant to the Agent upon completion of treatment.

I hereby agree to pay all costs of medical and dental care incurred by the Agent on behalf of the Participant.
CONSENT TO TRAVEL

I, as Parent/Guardian, do hereby authorize Participant to travel within the United States of America & Puerto Rico as set forth in the trip itinerary, and authorize Agent to make all necessary travel itinerary decisions on behalf of Participant.
MEDIA RELEASE CONSENT

I hereby grant permission to YOUTH FOR CHRIST PUERTO RICO the right to use, reproduce and/or distribute any photographs, films, video tapes and/or sound recordings of myself or my child, without compensation or approval rights, for use of material created for purposes of promoting future activities of YOUTH FOR CHRIST PUERTO RICO.

By signing below, the Participant/Parent/Guardian is stating that they have read and are in full agreement with the contents of this YOUTH FOR CHRIST PR, Inc. Consent & Release Form.
** If participant is under the age of 18, a parent or guardian must sign the following PDF printed out in front of notary public.

Click the link below to acces the pdf Consent & Release Form

RELEASE OF LIABILITY & CONSENT TO TREATMENT, TRAVEL & IMAGE RELEASE
Please attach PDF Consent & Release Form

Cancelof
Signature of Participant*

Clear
Date*

MonthDayYear
Date
Signature of Parent/Guardian

Clear
Date

MonthDayYear
Date
***By inserting your electronic signature on this document, you agree your electronic signature is the legally binding equivalent to your handwritten signature, and you are also confirming that you are the individual named in the electronic signature, and that you are authorized to sign this document.*

I/We Agree
Should be Empty:

YFC PR Mission Trip Release Form

Parent/Guardian Information

Emergency Contact Information

Medical/Health Information