Microsoft word - youth permission form.doc

YOUTH PERMISSION FORM
Youth’s Name______________________________________________ Date of Birth______________ CONTACT INFORMATION
Address________________________________________________________________ Home Phone_________________________ Youth’s Cell Phone_______________________ Parent/Legal Guardian Name__________________________ Daytime Phone___________________ Evening Phone___________________ Cell Phone_____________________________ Parent/Legal Guardian Name__________________________ Daytime Phone___________________ Evening Phone___________________ Cell Phone______________________________ MEDICAL INFORMATION
Doctor’s Name and Phone_____________________________________________________ Medical Insurance Company___________________________ Policy Number_____________________________ Member’s Name______________________ A photocopy of the insurance card must be attached to this form.
Please List any and all Allergies (food, medical, etc.): Please List any and all Medical Conditions: *Is the youth currently taking medication of any kind? _________ *If yes, please fill out a Youth Medication Form.

Leaders may administer the following medication or their generic equivalent if needed: Mark all that apply
By my signature, I ____________________________________________, the parent or legal guardian of _____________________________________________________, grant my permission for him/her to participate fully in any activities or trips sponsored by Providence United Methodist Church. This would include activities in the building, activities on the property, and activities off the property. I am confident that the leaders and sponsors will take appropriate care of my youth and every effort will be made for his/her safety. I understand that my signature carries with it the following: An authorization of the leaders to obtain necessary medical attention and/or treatment for my youth. Should medical help be needed, I agree to pay directly or through my own personal health and accident policy, all medical or hospital costs. Should medical help be needed and my own personal insurance is not accepted at the health care facility, I agree to make arrangements to reimburse the leader(s) who covered the cost of treatment immediately upon return. I knowingly release, absolve, indemnify and hold harmless Providence United Methodist Church from all claims that might result from any injury or death of my youth. This agreement pertains to all programs, events and activities including those where transportation is provided. I give my consent and permission for the taking of photographs and/or video of my youth during events and waive and/or assign any and all rights (including copyright) in such media to Providence United Methodist Church. Providence United Methodist Church, as the sole owners of such media, shall have the exclusive right to control and determine the use, display, performance, reproduction and dissemination of any such photographs and/or videos. Signature________________________________________________ Date___________________ Notary Information
The following is to be completed by the notary witnessing parent/legal guardian’s signature. The State of _________________________ the County of ________________________ Before me, a Notary Public, on this day personally appeared ____________________ known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this _______________________ day of __________________, A.D. ________________________.
Notary Public, Signature __________________________

My commission expires the _________ day of______________, A.D.______________.

Source: http://www.providencemethodist.org/share/docs/Media/document-8-YouthPermissionForm.pdf