CHILD/YOUTH MEDICAL/LIABILITY RELEASE WAIVER

Medical/Liability Release Waiver
CHILD/YOUTH MEDICAL/LIABILITY RELEASE WAIVER
Effective for one Calendar Year*
CHILD/YOUTH INFORMATION:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
School*
Grade*
Primary Address*
Secondary Address
Child/Youth Email*
example@example.com
Child/Youth Home Phone
Child/Youth Cell Phone*
Parent/Guardian Information:
Name*

First NameLast Name
Email(s)*
example@example.com
List all phone numbers where the parent(s)/guardian(s) can be reached.

Type: i.e. home, cell, work, etc.
Name*
Phone Number*
Please enter a valid phone number.
Type*
Name*
Phone Number*
Please enter a valid phone number.
Type*
Name
Phone Number
Please enter a valid phone number.
Type
Name
Phone Number
Please enter a valid phone number.
Type
Emergency Contact
Name*
Relation*
Phone Number*
Please enter a valid phone number.
Name*
Relation*
Phone Number*
Please enter a valid phone number.
Photo of your child*

Cancelof
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.
Medication Name Dose Treatment For Dispensing Instructions*
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 child/youth ministry event?

No. Contact me or get medical help if my child has any minor medical concerns.Yes. I give permission for an adult youth leader to give my child approved over-the-counter
Signature*

Clear
Primary Care Physician:
Name*
Phone*
Fax
Name of practice
Date of last Tetanus shot

MonthDayYear
Date
Medical Conditions:

Please answer in detail if applicable or write N/A.
1. List any medical conditions (asthma, diabetes, epilepsy, etc.)*
2. List any allergies(drug/medicine, food, and/or environmental) and the severity and type of reaction:*
3. List any swimming or activity restrictions*
4. Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know. *
Insurance Information:
Those without insurance coverage can simply write none or place zeros in the following boxes.
Medical Insurance Company*
Phone*
Policy/Group ID#*
Policy Holder's Name*
Photo of Insurance Card (Front)

Cancelof
Photo of Insurance Card (Back)

Cancelof
Medical/Liability Release Waiver

Parental Consent
The undersigned does hereby give permission for my childblanks* (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.
Name of youth participant*

First NameLast Name
Signature of youth participant*

Clear
Date*

MonthDayYear
Date
Name of Parent/Guardian *

First NameLast Name
Signature of parent/guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CHILD/YOUTH MEDICAL/LIABILITY RELEASE WAIVER

CHILD/YOUTH INFORMATION:

Parent/Guardian Information:

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

Emergency Contact

Medication:

Over-the-counter Medication Permission:

Primary Care Physician:

Medical Conditions:

Insurance Information:

Medical/Liability Release Waiver