Student Info & Permission Form
Greenback First Presbyterian Church- Youth Ministry- The FORGE
Email address *
Date *
Student Name (First & Last) *
Student's Gender *
Student's School *
Student's Phone Number
Parent / Guardian #1 Name (First & Last) *
Parent/Guardian #1 Phone Number *
Parent / Guardian #2 Name (First & Last)
Parent/Guardian #2 Phone Number
Address *
Student's Primary Physician & Phone Number *
List All Student Allergies and/or Any Important Health Considerations
Can Your Student Swim? *
In the event that neither parent/guardian can be reached in the case of an emergency, I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. *
I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the Church. I/We understand there are inherent risks involved in any ministry or athletic event, and I/We hereby release the Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our student’s involvement. In the event he/she is injured and requires the attention of a doctor, I/We consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministry’s staff. *
I give permission for my child to go on trips and offsite locations with Greenback First Presbyterian Church. I release Greenback First Presbyterian Church and individuals from liability in case of accident during church related activities, events, trips, and other offsite locations coordinated by Greenback First Presbyterian Church. *
For your information, we expect each student to conform to these rules of conduct
No possession or use of alcohol, drugs, or tobacco
No students are permitted to drive other students past curfew
No fighting, weapons, fireworks, lighters, or explosives
No offensive or immodest clothing
No boys in girls sleeping quarters and visa versa
Participation with group is expected
Respect property
Respect one another, staff, and adult leaders
Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home at their parent’s expense
I, the student, have read these rules of conduct, the above evaluation of my health, and permission to participate in Greenback First Presbyterian Church youth activities. I agree to abide by the stated personal limitations and code of conduct previously stated. *
Activities may include. But are not limited to: cookouts, campfires, boating, water skiing, wake boarding, swimming, basketball, roller skating, rollerblading, underwater basket weaving, games in the park, climbing, rappelling, soccer, crab soccer, icebreaker games, ice skating, volleyball, softball, baseball, camping, downhill skiing, caving, snowboarding, biking, hiking, concerts, Bible studies, golfing, miniature golf, hayrides, haunted maze, scavenger hunt, paintball, & service projects. Note: If you desire to limit your student’s participation in any event please submit your request in writing or in conversation to the youth leader prior to the event.
Please initial below if you have read and agree to the policies and release of liabilities above. *
A copy of your responses will be emailed to the address you provided.
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