BOISSEVAIN YOUTH GROUP PARENTAL CONSENT & WAIVER
We REQUIRE one form be filled out for EACH youth involved in our program. Be aware that all information in this form is confidential.
Sign in to Google to save your progress. Learn more
Personal Information
Name of youth "the minor" *
Youth Birth Date *
MM
/
DD
/
YYYY
Name of Parent (s) / Guardian (s) *
Address *
Parent Cell Phone Number (s) *
Parent Email Address *
6 Digit Family Medical Number *
9 Digit Personal Youth Medical Number *
Youth Cell Phone Number (if applicable)
Special Medical Conditions or Behavioral Information *
Please fill this in to help us provide the best care for your child and the other youth apart of our ministry. If you have nothing to say here, simply type 'none'
Allergies or Dietary information *
Please fill this in to help us provide the best care for your child and the other youth apart of our ministry. If you have nothing to say here, simply type 'none'
Other concerns or pertinent information *
Please fill this in to help us provide the best care for your child and the other youth apart of our ministry. If you have nothing to say here, simply type 'none'
Please read through ALL information below and check each box to show that you agree with each section.
I understand and acknowledge the risks involved in the minor’s participation in any youth programs, events or activities. I/we agree to hereby release and forever discharge Boissevain Mennonite Brethren Church, overseeing the Boissevain Youth Group, and its employees as well as any party volunteering with the youth group from all actions, causes of actions injuries, claims, damages, costs or expenses of any kind related to any activities the minor participates in. I understand that this is a full and complete release regardless of the specific cause thereof. *
Required
I further acknowledge and agree that I have given my consent for the minor to participate in all youth activities and to remain in the custody of (church) representatives for the duration of the activity. *
Required
In the event the minor suffers an injury or condition during their participation in any youth activity, including transportation, and reasonable attempts to contact me have been unsuccessful, I hereby appoint the Youth Pastor or leader in charge of the youth activity as my agent to act for me in my name to make decisions for the minor concerning personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when they are able to contact me. *
Required
I authorize the Boissevain Youth Group, it’s employees and volunteers, to take pictures/video of the minor for the purpose of promotion and/or posting in the youth room. *
Required
I also authorize the confiscation of the minor’s cell phone, other electronic devices or other personal items deemed inappropriate during youth activities at the discretion of the Boissevain Youth Group employees and volunteers. (item to be returned after the event) *
Required
I too authorize the leaders or volunteers to communicate with the minor outside of youth activities. *
Required
I am signing this form and realize it’s validity for the duration of the minor’s involvement in the Boissevain Youth Group and its activities. *
Required
Signature Section
Enter Today's Date *
MM
/
DD
/
YYYY
Type in the Legal Name of the Parent (s) / Guardian (s) *
This is acting as your signature. Completing this form shows you are in agreement with all of the Above Statements
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.