Youth Activity Consent Form

Parent/Guardian Info

First Name

Last Name

Email

Phone Number

Marital Status

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Number of Kids in Youth

Youth Info

First Name

Last Name

Gender

Birthdate

Medical Info

Is your youth presently being treated for an injury or sickness or taking any medication?

Injury, Sickness, Medication:

Other Conditions

Does your child ever sleepwalk?

Child's Blood Type (If Known)

Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?

Physical handicap or mental illness

Additional Info

Family Doctor

Family Doctor's Phone:

Insurance Co.

Policy No.

Consent & Certification

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of Revolution Church, and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events.

If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.

Note to Parent: If giving consent for one activity only, or if this consent is otherwise restricted, please specify:

Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or
becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth,
if required by law or a health care provide another adult chaperone designated by the pastor or by any other specified persons.

I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care.

I understand that Revolution Church will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the youth director in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the youth leader and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth.

Signature Of Parent/Guardian