Participant Emergency and Release Form

Participant Emergency and Release Form

Grace Presbytery Youth Events
Participant Information

Both youth and adult participants complete this section
Participant Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Gender*
Church *
Church Leader Email*
example@example.com
Parent or Legal Guardian Information

Complete for youth participants
Adult #1

First NameLast Name
Relation
Cell Phone

Area CodePhone Number
Email
example@example.com
Adult #2

First NameLast Name
Relation 2
Cell Phone 2

Area CodePhone Number
Email
example@example.com
Emergency Contact

Parent/Guardians listed above will be contacted first in event of emergency. Please list an additional emergency contact below in case parents cannot be reached. Adult participants - please provide an emergency contact.
Emergency Contact Name*

First NameLast Name
Emergency Number*

Area CodePhone Number
Emergency Contact #2

First NameLast Name
Emergency Number #2

Area CodePhone Number
Health Information

Please provide us with information that will help us to maintain your/your child's safety during this event or will assist in the event of a medical emergency.
Any activity the participant is restricted from?
Any physical, mental or other condition (including ADHD, autism, or sensory issues) that would be helpful for trip leaders to know?
List any allergies (ex: bees, peanuts, dairy)
Any dietary needs that we should know about?
List medications, both prescribed and over-the-counter. Medications should be brought in original containers in case of emergency.
Insurance Company
Insurance Policy Number
Insurance Co. Phone Number
Releases and Signatures
In the case of a medical emergency or the need for general medical care, youth leaders will contact listed parents and/or emergency contacts. Please check the box below to consent to youth leaders seeking necessary medical care for yourself or your child.

In the case of medical emergency or general medical care, I give consent for medical treatment for the above-named participant by authorized personnel.
Photos and videos will be taken during this event and may be used for publicity, including on social media, for Grace Presbytery youth ministries. Grace Presbytery makes every effort to protect the privacy and dignity of activity participants. We will not include biographical information with a minor's picture/likeness. Additionally, you or your child may request media containing you or your child's image to be removed at any time. Please check ONE box below.

I consent to the use of photos and videos of me/my child.I do not consent to the use of photos and videos of me/my child.
By signing and submitting this form, you agree that you are a participant in an event sponsored by Grace Presbytery or the parent or legal guardian of the above-named participant.

You agree that you/your child will refrain from the use of any alcohol, tobacco, e-cigarettes, or illegal substances during this event. In the event of violation of this rule, you/your child may be asked to leave the event immediately. Parents will be responsible for transportation for their child in the event they are asked to leave the event.

You acknowledge that the above-named person will participate in this event and its related activities, and use the facilities of the hosting institution at their own risk. You also consent to release, discharge, and indemnify Grace Presbytery of Irving, Texas and its directors, officers, employees, agents, and volunteers as well as the hosting institution/camp from all liabilities for damage, injury, or illness to the above-named participant or their property during their participation in or travel to and from this Grace Presbytery youth event.
Signature of Adult Participant or Parent/Guardian (for youth participants)*
Should be Empty:

Participant Emergency and Release Form

Participant Information

Parent or Legal Guardian Information

Emergency Contact

Health Information

Releases and Signatures