In Case of Emergency: Medical/Insurance Info &Parental Consent/Liability Wavier Form

This information form must be completed prior to participating in Crossway Church Youth Group Ministries. This form is current for twelve months following the signature completion date of this form. You are responsible for updating the following information with any changes that occur during that twelve month period.

Parent/Legal Guardian

This may only be completed by the child's parent or legal guardian.

Name

Child's Name

Child's preferred name

Child's gener

Male Female

Child's date of birth

Child's school

Grade entering the FALL of this year.

I give permission for the following:

An unchecked box means that you do not give permission for that activity.

For my child to receive Youth Ministry updates/communication For my child to participate in Youth Ministry group zoom meetings

Medical/Insurance Information

Does your child have any allergies or dietary needs that we need to be aware of?

Does your child have any medical conditions or disabilities that we need to be aware of?

Does your child have any particular learning needs?

Is there any other pertinent information about your child (i.e. physical, behavioral, or emotional) that would be important for adult leaders to know?

Please list any medications (names & dosage instructions) that your child takes on a regular basis.

Do you give permission for adult leaders to dispense over-the-counter medications?

Yes No Call first

Does your child wear contact lenses?

Yes No Option

Pediatrician's Name

Pediatrician's Phone Number

Are your child's immunizations up to date?

Yes No

Medical Insurance Provider

Name of Policy Holder

Insurance Group Number

Insurance Policy Number

Parents/Guardians

Mother/Guardian's Name

Mother/Guardian's primary phone number

Mother/Guardian/s secondary phone number

Mother/Guardian's Email

This address will receive a confirmation email

Father/Guardian's Name

Father/Guardian's phone

Father/Guardian's secondary phone

Father/Guardian's email

This address will receive a confirmation email

Marital Status?

Married Divorced Divorced/Remarried Single Widowed Other

Is there a special Custody Agreement that we need to be aware of?

Yes No

Custody Agreement Details

With whom does the child live?

Stepfather's Name

Stepfather's Phone

Stepmother's Name

Stepmother's Phone

Emergency Contact Information

If we are unable to contact a parent or legal guardian, in the even of an emergency, whom should we contact?

Emergency Emergency Contact Name

Relationship of emergency contact to the child

Emergency Contact Phone

Emergency Contact (2) Name

Relationship of emergency contact (2)to the child

Emergency Contact (2) Phone

Parental Consent

The undersigned does hereyby give permission for my child ("Participant") to attend and participate in any Crossway Church Youth Ministry activity, event, and retreat during the twelve months following the signature completion date of this form.

LIABILITY RELEASE

In consideration of Crossway Church allowing participants to participate in Youth Ministry (Bible class, Sunday worship, Activities, Events, Retreats, Lock-ins, Trips, etc.), I, the undersigned, do hereby release, forever discharge and agree to hold harmless Crossway Church, its Board, ministers, directors, employees, volunteers, teachers, agents, members, or any person affiliated with Crossway Church (collectively herein the "Church") from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in Youth Ministry activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in Youth Ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. The udersigned further hereby agrees to hold harmless the indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION:
I authorize an adult, in whose care the minor has been entrusted to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY:

Should it be necessary for my child to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION:

The undersigned does also hereby give permission for my child to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Crossway Church. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

This agreement shall be binding upon me and my heirs, successors and assigns. This agreement shall be governed by and construed in accordance with the Law of the State of Florida.

______________________________________________
I acknowledge that I have read this agreement and that I understand the words and language in it. I have been given the opportunity to ask any questions I have regarding the terms of this agreement and have been given the opportunity to have this agreement reviewed by my own legal representative prior to signing below.
_______________________________________________

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By typing my FULL NAME below, I certify that I am the parent or legal guardian of the Participant, and that I agree to the statements made within this Teen Ministry Participation Consent and Liability Release Form.
________________________________________________

Full Name of Parent or Legal Guardian

Date of Signed Consent

Name of Participant

In Case of Emergency: Medical/Insurance Info &Parental Consent/Liability Wavier Form

Description

Please Fix the Following