YOUTH MINISTRIES ANNUAL PERMISSION SLIP 2023-2024

I the listed parent/guardian, give permission for my child/children ("participants") listed to participate in the Life in Christ CRC regularly scheduled on-site events, any special events off-site, outdoor recreational activities, including travel, that are sponsored by Life in Christ CRC youth ministries during the following dates:

September. 1, 2023 to August 31, 2024

Primary Parent/Guardian/Emergency Name

Address

This address will receive a confirmation email

Primary Contact/Emergency Phone #

Secondary Contact/Emergency Name

Secondary Contact Emergency Phone #

1) Child Name

Child Cell Phone #

Grade in fall 2023

2) Child Name

Child Cell Phone #

Grade in fall 2023

3) Child Name

Child Cell Phone #

Grade in fall 2023

MEDICAL TREATMENT

Child/Children (partcipants) listed on this document has/have the permission of the undersigned to participate in Life in Christ church youth activities on & off site. In the event of an emergency affecting the health or welfare of this/these participant(s), the sponsors, leaders, or chaperones have permission to administer first aid and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual action in response to the emergency will be held blameless. Any medical expenses occurring will be paid for by the parents or guardians of the participant(s) listed.

RELEASE OF LIABILITY

I understand that activities sponsored and facilitated by Life in Christ Church that my child/children participates in, including but not limited to outdoor recreational activities, may have inherent risks for potential injury and I accept that risk on behalf of my child/children and myself.

Therefore, in consideration of my child’s/children's participation in activities conducted by Life in Christ Church, and as my child’s/children's parent or guardian, I hereby waive and release any and all rights and claims for damages (including damages for negligence) that I may have against Life in Christ Church or any of its officers, elders, pastors, volunteers, employees, or representatives for any and all injuries suffered by my child/children. I promise that I will emphasize to my child/children their responsibility to take reasonable precautions when participating in Church activities and to follow the safety directives of the Church staff.

Typing your name here is your signature to give consent to the Medical Treatment, Release of Liability & Permission to Participate (type your full name, first & last name)

MEDICAL MATTERS

I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child.

Medications: My child is taking medication at present (List below. If none, please type "none"). My child will bring all such medications necessary and they will be clearly labeled. My child will administer his/her own medication.

Choose one:

I hereby grant permission for nonprescription medication (such as ibuprofen, Tylenol, throat lozenges, cough syrup, etc) to be given to my child if deemed advisable. No medicating of any type whether prescription or nonprescription may be administered to my child unless the situation is life-threatening and emergency treatment is required.

Please list any known allergies:

Please list any physical limitations:

Please list any dietary needs/restrictions:

Are there any other issues that we should be aware of? If so, please explain:

PERMISSION TO USE MY CHILD'S IMAGE:

I recognize that Life in Christ church uses photographs and video images of events in our publicity materials such as the church website, social media and newsletters and I hereby grant permission for photo/video images of my child/children to be taken and used for such purposes.

YES NO

HEALTH INSURANCE & DOCTOR'S INFORMATION

Insurance Company (or type n/a)

Policy Number (or type n/a):

Policy holder's name (or type n/a):

Doctor's Name, Facility Name (or type n/a)

Doctor's Phone # (or type n/a)

Preferred Hospital for Emergencies (or type n/a or closest)

Council Approved Rev. 12/13/23

Description

Please fill out this form and click submit, this will be good for every youth group event until August 2024. If you need to make changes please contact Dawn (church administrator) at dawn@lifeinchristcrc.org.

YOUTH MINISTRIES ANNUAL PERMISSION SLIP 2023-2024

Description

Please Fix the Following