Salt Creek Baptist Church Youth Medical Release and Permission Form

Salt Creek Baptist Church Youth

Medical Release and Permission Form
Participant Name*

First NameLast Name
MaleFemale
DOB*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Insurance Company*
Policy #*
Mother's Name*
Phone Number
Please enter a valid phone number.
Father's Name*
Phone Number
Please enter a valid phone number.
Emergency Contact*
Phone Number*
Please enter a valid phone number.
Physician
Office Phone
Please enter a valid phone number.
Medical History

If necessary, describe in detail the nature and severity of any physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or condition to which your child is subject and of which the staff should be aware, and what, if any action of protection is required on account thereof. Submit this notification in writing in email or attached with a physical form to the youth pastor. Include names of medications and dosages that must be taken.
Check the following areas of concern for this student.
For your child’s safety and our knowledge, is your student a:

Good swimmerFair swimmernon-swimmer
Does your child have any allergies?

PollensMedicationsFoodinsect bites or stingsOther
Does your child suffer from any form, or has ever experienced, or is being treated for any of the following:

AsthmaEpilepsy/ Seizure DisorderHeart troubleDiabetesFrequently upset stomachPhysical handicap
Should your child's activities be restricted for any reason? Please explain
Date of Last Tetanus shot:

MonthDayYear
Date
Any Addisional comments or information we need to know:
Conduct Agreement
For your information, we expect each student to conform to these rules of conduct:

No possession or use of alcohol, drugs, or tobacco

No student can drive

No fighting, weapons, fireworks, lighters, or explosives

No offensive or immodest clothing

No boys in girls’ sleeping quarters and no girls in boys’ sleeping quarters

Participation with the group is expected

Respect property, other students, staff, and adult leaders

Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parents’ expense.

I, the student, have read the rules of conduct, the above evaluation of my health, and permission to participate in youth group activities. I agree to abide by the stated personal
Student Signature*

Clear
Today's Date*

MonthDayYear
Date
Activities may include, but are not limited to: cookouts, boating, water skiing, swimming, basketball, rollerskating, rollerblading, games in the park, soccer, broomball, ice skating, volleyball, softball, baseball, camping, downhill skiing, snowboarding, hiking, biking, concerts, Bible studies, golfing, miniature golf, hayrides.

Note: If you desire to limit your child’s participation in any event, please submit your wishes in writing to the church youth pastor before that event.
My Childblank Has permission to attend all youth activities

Sponsored by Salt Creek Baptist Church Youth Ministries

This consent form gives permission to seek whatever medical attention is deemed necessary and releases the Church and its staff of any liability against personal losses of named child.
I/We, the undersigned, have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and /or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.
Signature of Parent/ Guardian*

Clear
Today's Date*

MonthDayYear
Date
Video & Photography Release
IParents namegive permission for Students Nameto be photographed and/or videotaped for promotional use only. I hereby give permission for images of my child, captured during Salt Creek Baptist Church Youth Ministry events and activities through video, photo, and digital camera, to be used solely for the purposes of Salt Creek Baptist Church promotional material and publications, and waive any rights of compensation or ownership thereto. Examples of use include but are not limited to bulletin boards, website, Email newsletters, Facebook, & Instagram page. Pictures are published without last names.
Should be Empty:

Salt Creek Baptist Church Youth

Medical History

Check the following areas of concern for this student.

Conduct Agreement