Youth Activities Consent Form

Youth Name *

First

Last

Birth Date *

Name of Parent(s) or Guardian(s) *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Telephone *

Work Telephone

Other person and/or number to call in emergency

Medical Information:

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

Yes
No

If yes, please explain.

Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.)

Please explain.

Family Doctor:

Doctor's Telephone:

Insurance Co.:

Policy #:

Consent and Certification

I, the undersigned, being the parent of legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of Kingdom House and any other supervised activities customarily associated with its youth group, including youth rallies and overnight 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 health care provider: Pastor Josh Settles, Melissa Settles, Chuck Heath, or another adult chaperone designated by the church staff. I authorize these persons to act in my place or to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that Kingdom House 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.

Name of Parent/Guardian

Date