MBC: letter of informed consent

Mimico Baptist Church: Youth Ministry

LETTER OF INFORMED CONSENT
This form is for participants joining in regularly scheduled youth ministry programs on Friday nights.

Details of the Activity:
- Location: Mimico Baptist Church, Mimico Memorial Park
- Activities include: worship music, games, Bible study, prayer, activity planning, excursions to Mimico Memorial Park
Dear Parent/Guardian:

For participants who are under the age of 18, we do require your permission for your youth to participate. We have provided you the details of the activity and request that you complete and sign this permission form. The safety of your youth is our primary concern. Precautions will be taken for their well-being and protection.

For more information, contact our Youth Ministry Coordinator (youth@mimicobaptist.ca).
Student's Name*

First NameLast Name
Student's Email Address
example@example.com
Student's Cell Number

Area CodePhone Number
What other social media platforms do you use?

InstagramTikTokXFacebookSnapOther
The ways I can be reached are (select all that apply)

cell phoneemailsocial media (see above)phone callOther
Student's Date of Birth*

MonthDayYear
Parent's/Guardian's Name

First NameLast Name
Parent's/Guardian's Cell Phone

Area CodePhone Number
Parent's Email Address
Emergency Contact's Name (if not the parent/guardian)

First NameLast Name
Emergency Contact's Cell Phone (if not the parent/guardian)

Area CodePhone Number
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health Card Number
Family Doctor

First NameLast Name
Family Doctor's Phone #

Area CodePhone Number
Any special needs (dietary, disability, allergies)
What ways do you want to contribute to the youth group? (skills, gifts, resources, etc.)
What topics would you like to see addressed in youth group teaching/discussions?
I/we hereby consent to the participation of me/my youth in this supervised activity including travel to and from the locations listed above.

While every precaution is taken for the safety and good health, some activities carry with them the inherent risk of personal injury beyond the risks associated with this event. I/we understand and accept these risks and agree that by allowing me/my youth to participate in those activities, he/she may be taking part in a recreational activity that presents the potential for personal injury.

I/we, the participant and/or the parents/guardians named below, authorize the Pastor or designate of Mimico Baptist Church (MBC) to sign a consent for medical treatment and to authorize any physician, dentist or hospital to provide medical assessment, treatment or procedures for the participant named above.

I/we, named below, undertake and agree to indemnify and hold blameless Mimico Baptist Church, its Volunteers, Staff, Board of Directors and Officers from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Mimico Baptist Church, as well as of any medical treatment authorized by the supervising individuals representing MBC.

I grant MBC permission to contact me about any activities initiated or endorsed by MBC.

I grant permission for the reasonable use of pictures or video of me/my youth in any MBC publications (in print, online or other media yet to be invented).

I have read, understood and agree with above.
Student's Signature*

Clear
Parent's/Guardian's Signature (if student is under the age of 18 years)

Clear
Today's Date*

MonthDayYear
Should be Empty:

Mimico Baptist Church: Youth Ministry