Form

Alaska Baptist Church Youth Group
2014/2015 Youth Group Parent Permission/Medical Form

This permission & medical form gives the student named below permission to participate in the Alaska Baptist Student Ministry events from Sept 1st, 2014 - August 31, 2015. If you have any questions, please feel free to contact us at office@alaskabaptist.org

Student Information

Student's Name *

First Name Last Name

School Grade *

Current School Attending *

Birth Date

Month Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you play any instruments?

Do you play any sports?

Parent/Guardian Information

Full Name *

First Name Last Name

Home Number *

- Area Code Phone Number

Cell Number

- Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

- Area Code Phone Number

Alt. Phone Number

- Area Code Phone Number

Medical Information

If you have medical insurance, your carrier will be billed for medical charges in case of illness or injury while your youth is at the event.

Do you have medical insurance *

Yes No

Insurance Company

Policy #

In whose name is the insurance

Name of family doctor

Name & Dosage of any medication that must be taken and time

Any allergies?

Yes No

if Yes, please list allergies

If your student should require medical attention for any pre-existing or present conditions, please tell us the necessary information to give them proper medical care during the event:*

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities of Alaska Baptist Church during the selected session. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Alaska Baptist Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of travel to, participating in, or returning from service projects, events, concerts, conducted during the season.

I hereby acknowledge that if my child has to return home early for disciplinary actions, it will be at the expense of the parent/guardian.

In case of injury to said child, I hereby waive all claims against Alaska Baptist Church including all leaders and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Furthermore, all images and videos of Alaska Baptist Church Youth Group are the property of Alaska Baptist Church and can be used for any promotional consideration.

I hereby state that I have carefully read the above waiver. Acceptance and understanding of this agreement are hereby acknowledged.

I have read and agree to the Informed Consent and Acknowledgement.

Please initial *

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Alaska Baptist Church Director/Leader/Team Parent to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates of the registered sessions.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

I have read and agree to the Medical Release and Authorization.

Please initial *

Confirmation

By entering the information below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.

Parent/Guardian Full Name *

First Name Last Name

Confirmation E-mail *

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at office@alaskabaptist.org

Phone Number

- Area Code Phone Number