STUDENT RELEASE FORM

in order to participate in some youth activities require that a youth release form be filled out prior to the event. to do so you may fill out the form below or click the link at the bottom of this page to download and fill it out.

YOUTH RELEASE FORM

* Indicates required field

Student Name *

First

Last

AGE *

BIRTH DATE *

PARENT/GUARDIAN NAME(S) *

IN CASE OF EMERGENCY THE BEST PERSON TO CONTACT IS *

RELATIONSHIP TO STUDENT *

PHONE NUMBER *

SECONDARY PHONE NUMBER *

IS THE ABOVE PARTICIPANT ABLE TO SWIM? *

YES NO

IS THE ABOVE PARTICIPANT COVERED BY MEDICAL INSURANCE? *

YES NO

MEDICAL INSURANCE COMPANY *

GROUP # *

POLICY # *

SPONSORING ORGANIZATION: FBC MEDFORD (FIRST BAPTIST CHURCH, MEDFORD)

We, the undersigned parent/guardian of the above named participant, grant permission for the participant to participate in any event sponsored by FBC. We have been advised of the nature and extent of the activities that may take place and represent to you that the participant is physically and mentally able to participate in those activities. We understand that this activity, as any activity for youth, does present the risk of injury to the participant, and we have advised the participant of those possibilities. We represent to you that we and the participant assume the risk of any such injury or death and hold any employees, agents, representatives and volunteers of FBC harmless from any liability resulting from the conduct of the participant in this activity and agree to indemnify FBC, its employees, agents, representatives, and volunteers against any claim or liability. We authorize those representatives to arrange for such medical treatment as they may deem advisable for the health and well-being of the participant, understanding that immediate consultation to us will occur.

List of Youth Ministry activities: Dodgeball, Encounter Weekend, Mission Trips, Summer Fellowship Nights, swimming, running, rafting, water skiing, sporting games, eating, riding in authorized vehicles, hiking, biking, camping, community projects, camp fires, etc.

PLEASE LIST ANY FOOD OR MEDICAL ALLERGIES AND/OR MEDICAL CONDITIONS (IF NONE, PLEASE TYPE "NONE") *

We also authorize transportation by an insurance approved driver of FBC.

PARENT/GUARDIAN SIGNATURE (TYPING YOUR NAME IS YOUR ELECTRONIC SIGNATURE) *

DATE *

I, the participant, understand that I am under the authority of those leaders in charge. I also understand that the use or possession of alcoholic beverages, illegal drugs, tobacco, fireworks, firearms, knives, foul language, and/or abusive or sexual behavior are prohibited, and will result in immediate expulsion, at the expense of myself or parent/guardian. I understand that this is a Christian event and will have a spiritual emphasis. I have read and discussed this guidelines with my parent/guardian.

PARTICIPANT SIGNATURE (TYPING YOUR NAME IS YOUR ELECTRONIC SIGNATURE) *

DATE *

Submit

download pdf version here

sm_release_form_2018-2019.pdf
File Size:	51 kb
File Type:	pdf

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release form

YOUTH RELEASE FORM

download pdf version here

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