Youth Group Consent, Information and Release Form

Youth Permission Form

Bethlehem Baptist Church Youth Ministry Medical & Liability Release Form

Name of Student(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date(Required)

Please enter the birthdate of the youth member attending the event.

Consent and Release Agreement(Required)

I agree and consent to all items in the statement below.

I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Bethlehem Baptist Church (Madisonville, TN) Youth Ministry, both on and off church grounds, including the necessary transportation to and from these events and activities. Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the child affected; (3) I cannot be personally contacted. I further agree not to hold Bethlehem Baptist Church (Madisonville, TN) or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless Bethlehem Baptist Church (Madisonville, TN) for all claims made and liabilities assessed against them as a result of any event or activity. I release Bethlehem Baptist Church (Madisonville, TN) and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity. Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be re-turned home due to disciplinary action (when on trips), I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation. By signing below checking yes, I am acknowledging that I have read through and understand the below statements.

Electronic Signature(Required)

By entering your name, you agree to sign the consent for this listed student.

In Case of Emergency, Please Contact:

Name of Contact 1(Required)

First Last

Phone(Required)

Relationship to Student(Required)

Name of Contact 2

First Last

Phone

Relationship to Student

Medical Information

Name of Physician

Physician or Medical Provider Phone Number

Medical Insurance Provider

Policy Number

Name on Insurance Card

Please list any allergies, medications or other applicable medical information needed for your student.(Required)