ORGANIZED YOUTH ACTIVITIES PARTICIPATION & RELEASE FORM

ORGANIZED YOUTH ACTIVITIES PARTICIPATION & RELEASE FORM
Student Information
Student/Participant's Name

First NameLast Name
ZIP Code
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Allergies- Food
Allergies- Environmental
Allergies- Medication
Any Other Medical Needs or Considerations, if so, Please Explain
Physician and Insurance Information
Physician Name
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Policy and/or Group Number
Participation and Release Form

Parents, Please initial following each Section
I give permission for my child (Participant), to attend and participate in any Lakewood Baptist Church youth ministry activities, events, and retreats.- PLEASE INITIAL BELOW
LIABILITY RELEASE: In consideration of Lakewood Baptist Church allowing the Participant to participate in youth ministry activities, events, and retreats, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Lakewood Baptist Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. - PLEASE INITIAL BELOW
MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any licensed physician or dentist on the medical staff of a licensed hospital or emergency care facility in any state or the District of Columbia. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. - PLEASE INITIAL BELOW
TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child to ride in any vehicle driven by an approved and licensed ADULT Youth Worker while attending and participating in activities sponsored by Lakewood Baptist Church. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. - PLEASE INITIAL BELOW
I DO grant to Lakewood Baptist Church, its representatives and employees the right to take photographs of me, my property and my children in connection with the above-identified subject. I authorize Lakewood Baptist Church, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Unity Baptist Church may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. - PLEASE INITIAL BELOW
Parent/Guardian Information
I have read and understood the foregoing registration liability release and parental consent form and agree to all of its terms and conditions as completed.
Parent/Guardian Printed Full Name
Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact's Name

First NameLast Name
Relationship
Emergency Contact's Name
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Parent/Guardian's Signature
Should be Empty:

ORGANIZED YOUTH ACTIVITIES PARTICIPATION & RELEASE FORM

Student Information

Physician and Insurance Information

Participation and Release Form

Parent/Guardian Information