Grays Harbor Immanuel Baptist Church - Youth Trip Consent Form

As iron sharpens iron, so one man sharpens another.

Proverbs 27:17

Contact Information

Name Of Youth

Birth Date

Parents/Gurddians

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Home Phone

Work Phone

Emergency Contact

Medical Information

Is youth being treated for an injury, illness or takes any medication?

Yes

No

Please describe

Please Explain

Family Doctor

Doctor Phone

Insurance Co.

Policy No.

Consent & Certification

I, the undersigned, being the parent or legal guarding of the youth named above, do hereby consent to the participation of my youth in all scheduled youth activities of Immanuel Baptist 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 specific activity only, or if this consent is otherwise restricted, please specify:

Medical Treatment Authorization

I understand that I will be notified in case of a medical emergency. However, in the event that I cannot be reached, I authorize host parties to contact doctor and to provide 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 of a health care provider:

Name if applicable

another adult chaperone designated by the pastor and Don Shuh.

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

I understand that Don Shuh 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.

Parent/Guardian Signature

Youth Pledge

I hereby pledge to uphold all policies of the Youth Department at Immanuel Baptist Church. During all youth activities and all youth trips, I pledge to follow all instructions of the youth leader and the adult chaperones, including safety instructions.

Youth Signature

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