Northside Youth Ministry Release Forms 24-25

This consent form gives permission to seek whatever medical attention is deemed necessary. Releases Community House Presbyterian, Riverview United Presbyterian, and Mosaic Community Churches and their staff of any liability against personal losses.

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Email *
Student's Name *
Parent 1 or Legal Guardian 1 Name, Relation, and Phone Number, Pronouns *
Parent 2 or Legal Guardian 2 Name, Relation, and Phone Number, Pronouns
Emergency Contact Name, Relation, and Phone Number *
Address *
Student's Pronouns *
Required
Date of Birth *
MM
/
DD
/
YYYY
Student Phone Number
Grade *
Student Shirt Size *
If your student is involved in extra curriculars, which ones are they involved in?
Dietary Restrictions
Health Concerns (Allergies, etc) and Medications
Health Insurance Number, Provider, and PCP Name and Phone Number *
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 Consent Release: I willingly allow my child to participate in events/programs organized by Community House and Riverview.  In the event that he/she/they is injured and requires the attention of a doctor, I 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 agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I 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 affirm that the health insurance information provided above is accurate and active for any care my child may require.   
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Chaperone Release: I give permission for my child to participate in all activities planned by Community House and Riverview. I support the Youth Director and adult leaders chaperoning these activities, and I give them permission to take reasonable action, as they deem necessary, to protect the best interest of my child.
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Passenger Release: I give permission for my child to ride with a youth leader or approved driver. I understand that every care will be taken to ensure the health, safety, and welfare of my child.
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Waiver Release: I give permission for youth ministry leadership to sign release forms at mission partnership activities (homeless ministry, service trips, etc.) as the designated adult.
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Media Release: I give my permission for Community House and Riverview United Presbyterian Churches to use any form of media of my child on their website, social media sites, and for media releases (web & print) in which to advertise a church event.
 *
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