Youth Permission/Waiver Form
"Working together to build safe spaces for children in Christ's name."

Fill out this form for your child/youth to participate in programs and activities at Bethesda Mennonite Church.

Email address
Today's Date
MM
/
DD
/
YYYY
Name of Youth Participant
Your answer
Parent(s) or Legal Guardian(s) of Youth
Your answer
Complete Address (Street, City, State, Zip)
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
Your answer
Email Address
Your answer
Age of Youth
Your answer
Birthdate of Youth
MM
/
DD
/
YYYY
Grade Completed
Functions & Activities: It is my understanding that participating in the programs and activities of Bethesda Mennonite Church is a privilege. I acknowledge that there are certain risks associated with the activities including activity-related accidents and physical injury due to transportation-related accidents.
Release of Liability: By signing this Permission/Waiver Form, I assume all risks of the above named youth participating in the activities. I further release Bethesda Mennonite Church and its ministers, leaders, employees, volunteers and agents from any claim that my child may have against them as a result of injury or illness incurred during the course of participation in the activities.
First Aid & Emergency Medical Treatment: I recognize that there may be occasions where the youth named above may be in need of first aid or emergency medical treatment as a result of a Bethesda Mennonite Church accident, illness or other health condition or injury. I do hereby give permission for agents of Bethesda Mennonite Church to seek and secure any needed medical attention or treatment for the youth name above including hospitalization. If in the agent's opinion such need arises, in doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment.
Medical History - Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.)
Your answer
Health Insurance Company
Your answer
Health Insurance Policy Number
Your answer
Medical Doctor
Your answer
Medical Doctor Phone Number
Your answer
Emergency Contact(s): Names of persons and telephone numbers to call in case of emergency.
Your answer
I represent that I am the parent/guardian of the above named child, who is under 18 years of age. I have read the above Youth Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the youth named above to participate in the activities of Bethesda Mennonite Church. In consideration for allowing the participation of the youth in the activities of Bethesda Mennonite Church, I hereby consent to the Youth Permission/Waiver Form, including the Release of Liability above, on behalf of the youth, and agree that this Youth Permission/Waiver Form shall be binding upon me. Please enter your signature (type or write your name).
Your answer
Today's Date
MM
/
DD
/
YYYY
Photo Permission: I also give permission for photos of the youth named above to be used in written and internet publications.
Required
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Bethesda Mennonite Church. Report Abuse - Terms of Service - Additional Terms