Memorial Baptist Church Youth Ministry

Youth Activity Consent Form

Date:__________________

School:____________________________

Name:_________________________________ Birthdate:____________ Grade:_____

Address:_______________________________________________________________

City:______________ State:____ ZIP:__________

Phone(s):__________________________________

(Include Town & Zip Code)

Allergies:______________________________________________________________

Diabetic (Y/N):____ Insulin (Y/N):____

Medications:____________________________________________________________

Childhood Diseases: Chickenpox___ Measles___ Mumps___ Other_______________

PERMISSION TO ATTEND ACTIVITIES & RECEIVE

MEDICALTREATMENT

AI, the undersigned, am the parent/guardian of_________________________. I give consent for him/her to participate in Youth Activities sponsored by Memorial Baptist Church of Murray, KY. In the event of an injury arising while attending a church-sponsored activity, on or off the church grounds, I give permission for the church staff or volunteer adult staff or chaperons, to secure medical treatment (including surgery) for my child by qualified medical personnel, including licensed physicians and certified emergency medical technicians (EMTs).

I, the undersigned, do hereby verify that the above information is correct, and I do hereby release and discharge Memorial Baptist Church and chaperons from any and all claims, demands, actions or cause of actions, past, present, or future arising out of any damages or injury while participating in our Youth Ministry Programs.

In the event of a change in the medical condition of my child, I will notify Memorial Baptist Church prior to my child’s participation in future events. I understand that I can revoke this medical release at any time upon written notification to the Director of the Memorial Baptist Youth Programs & Activities.

Signature:____________________________

Date:_________________

Emergency Phone Numbers:_________________________________________

Insurance Company:____________________ Policy No.___________________

Family Physician:_______________________

Physician Phone:_______________________