2025-26 Health, Consent & Release of Liability Form Logo
  • Health, Consent & Release of Liability Form 2025-26

  • Student Information

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  • Rebalance Data and Survey Agreement

    I, the Undersigned, agree when I or my child participate in surveys regarding the activities of CMYFC/Rebalance programing, the data can be used by CMYFC/Rebalance staff provided the identity of myself and my child will not be disclosed. In the furtherance of this, I allow data obtained to be used by an outside research lab to provide non-identifiable survey summaries. UNDER NO CIRCUMSTANCES SHALL THE IDENTITY OF MY CHILD BE DISCLOSED TO ANYONE FROM THESE SURVEYS.

    I give consent for the staff and volunteers of CMYFC/Rebalance to keep electronic notes in regard to their interactions with my child. I give consent for these notes to be shared with agencies or schools or individuals involved with my child.

  • Emergency Information

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  • Health Insurance Information

  • Health Information



  • Demographic Information

    *We receive several grants and scholarships for our programs. The questions in this section are ones we need to report to the grants on in order to continue to receive funding and to make scholarship money available to our students. If you prefer not to answer these questions, you can leave them blank.

  • Parental Consent and Release of Liability 
    For Central MN Youth For Christ  Period: 5/15/2025 - 6/1/2026

  • 1. RELEASE OF LIABILITY - “I give my permission to participate in YFC activities. I understand accidents can happen when doing fun activities and accept the risks. I or my child agree to come to YFC activities healthy.” 

    I understand that the opportunity to participate in CENTRAL MN YOUTH FOR CHRIST, et al (“YFC”) activities is a privilege. I am signing this Release of  Liability form on behalf of myself or my minor child. I understand that my child or I may participate in any number of physical activities some of which  include, but are not limited to, recreational activities and games and events. I understand that there are certain risks of physical injury or illness associated with these activities. In addition, I understand that there may be other risks associated with activities of which I may not be presently  aware.  

    By signing this Release, I expressly assume these risks for myself or my minor my child, whether they are known or unknown to me at this time and  certify that I or my child is healthy and fit to participate in all YFC activities. I release CENTRAL MN YOUTH FOR CHRIST, including its affiliated chapters,  affiliates, and their officers, directors, volunteers, employees, contractors and agents, from any claim that I or my child may have now or in the future  against them for any accidental physical or other personal injury, loss of personal property, illness or death caused by infectious and/or contagious  diseases or sickness while at camp or other YFC activities, or during YFC travel to and from camp or other YFC activities, and any medical responses  to the same, as well as any other claims arising from participation in CENTRAL MN YOUTH FOR CHRIST et al activities. This release of liability shall cover  (without limitation) all claims for negligence and breach of fiduciary duty asserted by my child, myself or any person made on their behalf. This  Release specifically covers claims caused in whole or in part by any U.S. national health crisis, epidemic, pandemic, or similar widespread outbreak of  disease whether or not such is formally declared by the U.S. government, the Center for Disease Control or the World Health Organization. YFC  reserves the right to follow recommended CDC guidelines related to such pandemic, outbreak or disease and as such may choose at any time to  send a participant home if presenting signs of sickness. 

    2. INDEMNIFICATION – “I agree to hold YFC harmless.” 

    I hereby agree to defend, indemnify and hold CENTRAL MN YOUTH FOR CHRIST, including its chapter affiliates, their directors, volunteers, employees,  contractors and agents, harmless from any liability asserted by me or my child subsequent to his or her 18th birthday, including reasonable attorney's  fees and costs.  

    3. AUTHORIZATION FOR MEDICAL TREATMENT - “If an accident happens and if I cannot be reasonably reached, I give permission for  emergency medical treatment and promise to cover medical costs if treatment is needed.” 

    I understand it may be necessary to have a medical consent form present for medical professionals in the unlikely event of an injury or condition  requiring medical treatment of me or my child. This form gives YFC and its personnel the permission to take me or my child to the nearest, capable medical facility and have any necessary emergency treatment administered.  

    IF PARTICIPANT IS A MINOR: IN CASE OF EMERGENCY, I UNDERSTAND THAT EFFORTS WILL BE MADE TO CONTACT ME; HOWEVER, IF I  CANNOT BE REACHED, I HEREBY GIVE CENTRAL MN YOUTH FOR CHRIST AND ITS REPRESENTATIVES THE PERMISSION TO ACT ON MY BEHALF IN SEEKING EMERGENCY MEDICAL TREATMENT FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY OR ADVISABLE FOR MY CHILD'S HEALTH, SAFETY AND WELFARE. I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO, USING THE  MEASURES DEEMED NECESSARY. I RELEASE CENTRAL MN YOUTH FOR CHRIST, ITS REPRESENTATIVES, AND ALL MEDICAL PROVIDERS FROM  LIABILITY IN ACTING IN THIS REGARD AND RENDERING SUCH MEDICAL TREATMENT. I WILL BE FULLY RESPONSIBLE FOR ALL SUCH MEDICAL  EXPENSES.  

    IF PARTICIPANT IS 18 OR OVER: IN CASE OF EMERGENCY, AND AM UNABLE TO REPRESENT MYSELF, I HEREBY GIVE CENTRAL MNYOUTH FOR CHRIST AND ITS REPRESENTATIVES THE PERMISSION TO ACT ON MY BEHALF IN SEEKING EMERGENCY MEDICAL TREATMENT FOR MY PERSON IN  THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY OR ADVISABLE FOR MY HEALTH, SAFETY AND WELFARE. I GIVE PERMISSION TO  THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO, USING THE MEASURES DEEMED NECESSARY. I RELEASE CENTRAL MN YOUTH FOR CHRIST, ITS REPRESENTATIVES, AND ALL MEDICAL PROVIDERS FROM LIABILITY IN ACTING IN THIS REGARD AND RENDERING SUCH MEDICAL  TREATMENT. I WILL BE FULLY RESPONSIBLE FOR ALL SUCH MEDICAL EXPENSES.  

    4. MEDIA RELEASE - “YFC can use pictures and other media of me or my child participating in YFC activities for promotional purposes. 

    I hereby grant permission to CENTRAL MN YOUTH FOR CHRIST the right to use, reproduce, and/or distribute any photographs, film, video and sound  recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of CENTRAL MN YOUTH FOR CHRIST  

    5. BEHAVIORAL AGREEMENT – “YFC hates sending participants home, but sometimes they have to. I recognize that.” 

    I understand that illegal, immoral activity, or behavioral issues may result in the named participant being sent home at the expense of the  parent/guardian. Activities would include but are not limited to: reasonable belief of possession and/or use of drugs, alcohol, weapons; sexually  aggressive and/or inappropriate behavior; stealing; fighting; etc. YFC leaders will make reasonable effort to contact the parent/guardian to make  arrangements before a participant is sent home. 

    6. MEDICATION INFORMATION - Any medication brought a program/event must be accompanied by written instructions from a physician/parent. All prescriptions must be brought in the original container in which they were issued (with medical instructions, dosage information, etc.).

  • Confirmation and Signature

    I have read the above waivers/releases and understand what I have read.
    I represent that I am the participant named below (if 18 or over) or the legal parent/guardian of the child named below, who is under 18 years of age. In consideration for allowing my child to participate in this activity and ongoing YFC activities, I hereby consent to the foregoing on behalf of my child and agree that this release shall be binding upon me, my child, our heirs, legal representatives and assigns.

    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.

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