YFC Summer 2025 Waiver
Complete this waiver one time (per student) for summer recreation events with Youth For Christ/Campus Life.
PARTICIPANT INFORMATION:
Participant Name
*
First Name
Last Name
Participant Phone Number
Participant Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Participant School
*
Grade Entering
*
6
7
8
9
10
11
12
Just Graduated (2025)
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PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name
*
First Name
Last Name
Address (if different than student address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
SECONDARY EMERGENCY CONTACT:
Secondary Emergency Contact
*
First Name
Last Name
Phone Number
*
AUTHORIZED PICKUP PERSON(S):
If different than the names listed above.
Authorized Pickup Person(s)
First Name
Last Name
Authorized Pickup Person(s) Phone Number
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MEDICAL INFORMATION
**If you do not have a physician or medical insurance, please put N/A in the spaces provided.**
Physician Name
*
First Name
Last Name
Physician Phone Number
Has the participant had a physical within the last 24 months?
*
Yes
No
Medical Insurance Company
*
Policy Number
*
Allergies - check those that apply and specify nature of allergic reaction below:
*
None
Animals
Environmental
Medication
Food
Insects
Latex
Other
Specific Allergy
Medical Concerns
Please provide any additional information about your participant's health that you think important or that may affect their ability to participate in YFC activities.
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LIABILITY RELEASES
These releases MUST be completed by the parent/guardian of the participant, unless the participant is 18 years of age or older.
YFC Consent and Release of Liability: I represent that I am the participant named (if 18 or over) or the legal parent/guardian of the child named, 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.*
I, the undersigned, agree to the terms above.
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: