YOUTH GROUP INFORMATION AND PERMISSION FORM 2023 - 2024
SPINNING ROAD BAPTIST CHURCH
538 Spinning Road, Riverside, OH 45431

This form is valid: August 1, 2023 — Aug 31, 2024

To enroll your child in the Youth Group at Spinning Road Baptist Church (SRBC), please complete this form.  Youth Group registration personnel will print out the form and have you sign it later. 
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STUDENT INFORMATION:
Youth's First Name *
Youth's Last Name *
Goes By
(nickname, if any)
Gender *
Age *
Birth Date *
MM
/
DD
/
YYYY
Grade *
(Grade as of fall 2023)
School *
Youth's Email
Facebook Access?
Youth's Phone Number
(including area code)
Text?
ADULT CONTACTS:
Parent(s) / Guardian(s) Name(s) *
Primary Phone Number *
(including area code)
Secondary Phone Number
(including area code)
Work Phone Number
(including area code)
Email Address *
(Where we can reach you for Youth Group announcements and updates)
Address *
City *
State *
Zip Code: *
T-Shirt Size
T-Shirts are free.  Please choose a size below.
Clear selection
Person(s) other than Parents authorized to pick child up
(please note: your child will not be let go to anyone other than you and those listed below)
Emergency Persons and Phone Numbers:
In Case of Emergency and Neither Parent Can Be Reached, Contact the Following:
Emergency Contact *
(Other than Parent(s) or Guardian on this form)
Emergency Contact Cell Phone Number *
(including area code)
Emergency Contact Home Phone Number
(including area code)
Emergency Contact Relationship to Youth *
MEDICAL INFORMATION (REQUIRED FOR ALL OFF‐CAMPUS ACTIVITIES)
If your child should require medical attention for injuries received or illnesses contracted prior to activities with the Spinning Road Baptist Church Youth Group, please send us the necessary information to give him/her proper medical care during his/her time with the youth ministry activity.
Medical History:
Immunizations current/up to date *
Date of last tetanus/diphtheria immunization
MM
/
DD
/
YYYY
Check all items your child is allergic to *
Choose "None" if there are no known allergies.  There will be an opportunity to describe any allergies in the next question
Required
Important allergy details
For instance, if foods were checked in the previous question, what foods is your child allergic to?
Swimming ability *
Choose an option that best describes your child
Check all items your child currently suffers from or has ever suffered from
Does your child have a reaction to any of the following *
Choose "None" if there are no known reactions.  There will be an opportunity to describe any reactions in the next question
Required
Important reaction details (if any)
Check all items your child wears *
Choose "None" if no items are worn
Required
Special Dietary Needs
Activity Restrictions
Any physical limitations or anything else the staff should be aware of?
Medications your child takes regularly (name/dose/times/etc.)
OVER THE COUNTER MEDICATION PERMISSION *
Do you give permission for your child/youth to be given over the counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?
MEDICAL CARE INFORMATION
Name of Primary Care Physician
Physician's Phone Number
Dentist's Name
Dentist's Phone Number
If you do not carry medical insurance at this time, put your initials below
Health Insurance company - in the event your child needs medical attention
Health Insurance policy #
YOUTH GROUP RELEASES
GENERAL RELEASE: I give my consent for my son/daughter to attend youth group meetings, activities, & events, both on site and off site. I will be provided specific event information in advance for any activity that will be taking place both on site and off site.
TRANSPORTATION: Should transportation be needed; I give permission for my child to ride in any vehicle driven by an approved and licensed ADULT chaperone (21 years of age or older) while attending and participating in activities sponsored by SRBC. My child and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
MEDICAL RELEASE: In the event of an emergency, I as a parent/guardian of the above-named child, give permission to the physician/hospital selected by SRBC leaders to consent for any x-ray, medical, dental, examination, anesthetic, release of insurance records; medical or surgical treatment, and hospital care which is advised and supervised by a licensed physician, surgeon, or dentist for my child. which, in the doctor’s opinion, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed for the above-named child at parent’s expense. I authorize an adult youth leader of SRBC’s youth group, authority to act as agent for me, on behalf of my above-named child to; provide or arrange necessary related transportation, including paramedics, and ambulance transport. This authority is granted only after a reasonable effort has been made to contact me or my emergency contact. I hereby agree to fully pay all costs of medical or dental care connected with this treatment, and/or incurred by SRBC or their agent. I hereby release Spinning Road Baptist Church, Pastor, volunteers, agents, and vehicle driver of any vehicle driven (if transportation is part of an event) from liability. This release form is completed and signed of my own Free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
PHOTO / VIDEO RELEASE:
PHOTO / VIDEO RELEASE: Occasionally photos/videos may be taken during Sunday school, worship, youth group events, or other church activities. Photos / Videos taken during the year are used to promote our Youth Program on the Church website. If you would prefer not to have individual pictures of your child included, please indicate below. We cannot guarantee that your child will not be included in group photos / videos of Youth Group events.
Individual pictures of my Child at Youth Group events *
(Check one)
Required
CELL PHONE POLICY: Most electronic devices are not allowed during youth group meetings and events. The reason for this is to create an environment that is free of distractions where the youth can focus on each other and God. Cell phone use, including texting, will ONLY be allowed if permission is granted by the youth leader. Phones should be silent and not used during meetings and events.If a student uses a cell phone for other than emergency reasons or without permission from a youth leader the cell phone could be taken away until the end of the event. Students who fail to comply with these expectations may be sent home at their parents' expense.
I have read and understand the cell phone policy (place initials below) *
Parent/Guardian Signature
(Youth Group personnel will print out the form and have you sign it in person)
Date
(when you sign the form, please put the date here)
Thank you for beginning the registration process by filling out this electronic form.  Youth Group registration personnel will print out the form and have you sign it in person the first time your child attends.  Press the submit button below to complete the sign-up process.
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