Plymouth Presbyterian Church Youth


Permission Form: 2014-2015


I give my permission for _______________________________ to participate in

Plymouth Presbyterian Church youth group activities. I will notify the specific group leaders if my child does not have permission to attend a specific event. I understand that special events may require a separate permission form. I agree to direct my child to cooperate and conform to directions and instructions of personnel (volunteer or staff) responsible for activities.


I have completed the annual Medical Information/Release Form and it is on file in the church office. I agree that in the event my child is injured as a result of his/her participation in the above-named activities, including transportation to and from these activities, whether or not

caused by the negligence (active or passive) of the activity or the church program, or any of its agents or employees, recourse for the payment of any hospital, medical , dental, or related costs and expenses will be paid either by me or my spouse, accident, hospital or medical insurance, or any available benefit plan of mine or my spouse.


I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physical, surgeon, and dentist licensed under the Medical Practice Act and Dental

Practice Act. As parent or legal guardian, I am responsible for the health care decisions of my child and am authorized to consent to services to be rendered, and no other consent is required by law. I hereby give permission to the physician selected by the activities supervisory personnel then present to render medical treatment deemed necessary and appropriate by the physician or dentist.


In the event of an emergency, I give permission to the church staff or youth advisors to seek appropriate medical attention for my youth. Every attempt will be made to notify me immediately of such an emergency. I understand that while Plymouth Presbyterian staff and volunteers will do their best to insure my child’s safety, they cannot take responsibility for any injuries to my child that are reasonably beyond their control.


I understand that photographs may be taken of any youth event and its participants and I give permission for these photographs to be displayed, posted, or shown on the church website, within the church building, or used for other church-sponsored activities. At no time will my youth’s full name be used with these pictures in a public forum (web-pages, materials sent to non-church members, etc.).


____________________________________ ____________________________________


 Parent or Guardian Signature Parent or Guardian Printed Name


Youth’s Full Name______________________________________________________________

Birth date_________________________ Phone number ______________________________



Youth e-mail and cell: ___________________________________________________________


Can you receive texts about youth group? Yes No


* Scholarship monies are available confidentially for events with prior arrangements made through the pastor(s), staff, or volunteer youth advisor(s).


Medical Information/Release Form for the 2014-2015 School Year



Youth’s Full Name _____________________________________________________________


 First Middle Last



Emergency Contacts


Name of Father or Guardian_______________________________________________________


Name of Mother or Guardian ______________________________________________________


Home Phone Number(s)___________________________________________________________


Work Phone Number(s)___________________________________________________________


Cell Phone Number(s) for guardian(s)_______________________________________________


Cell Phone Number for student_____________________________________________________


 If Parents Cannot be reached:


First Contact___________________________________________________________________


Name Relationship Phone #


Second Contact_________________________________________________________________


Name Relationship Phone #


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


Signature:_______________________________________ Date:_________________________



Medical Information


Name of Insurance______________________________________________________________


Group Number________________________ Member Number___________________________


Allergic reactions_______________________________________________________________


Date of last tetanus/diphtheria immunization:_________________________________________


Medications Used _______________________ Dosage ________________________________




Special diet?___________________________________________________________________


Any physical limitations?_________________________________________________________


Known Medical Conditions_______________________________________________________


Family Doctor_______________________ phone number ______________________________


Family Dentist _______________________phone number ______________________________


For overnight trips or special circumstances: Is youth subject to chronic homesickness,

emotional reactions to new situations, sleepwalking, bed wetting, fainting or seizures?





Please return to church office.