• Medical/Liability Release Waiver

  • CHILD/YOUTH MEDICAL/LIABILITY RELEASE WAIVER

  • CHILD/YOUTH INFORMATION:

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  • Parent/Guardian Information:

  • List all phone numbers where the parent(s)/guardian(s) can be reached.

    Type: i.e. home, cell, work, etc.
  • Emergency Contact

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  • Medication:

    List all medications the child/youth will take during any child/youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Child/Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian's expense if they do. If non-applicable put N/A.
  • Over-the-counter Medication Permission:

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  • Primary Care Physician:

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  • Medical Conditions:

    Please answer in detail if applicable or write N/A.
  • Insurance Information:

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  • Medical/Liability Release Waiver

    Parental Consent
  • The undersigned does hereby give permission for my child* (child's name) ("Participant"), to attend and participate in any Journey Church children/youth ministry activities, events, retreats, and childcare during the current calendar year.

  • LIABILITY RELEASE:

    In consideration of Journey Church A/G allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Journey Church A/G (a dba of First Assembly of God, Minot, ND), its pastors, directors, employees, teachers, and volunteers (collectively herein the “Church”) or any family of the Church hosting any Journey Church A/G event or ministry activity at their home or on their property, from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful, or intentional acts of said Participant, including expenses incurred attendant thereto.

    MEDICAL TREATMENT PERMISSION:

    I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist of a licensed hospital or emergency care facility as deemed necessary. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

    TRANSPORTATION PERMISSION & EARLY RETURN HOME POLICY:

    The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Journey Church A/G. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation. Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibility.

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