Youth - Parent/Guardian Consent Form - Shoreline Covenant Church

Youth – Parent/Guardian Consent Form

"*" indicates required fields

Youth Information

Name*

First Last

Birth Date*

MM slash DD slash YYYY

Grade in School*

Please enter a number from 0 to 12.

School Attending*

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Parent/Guardian Information

Parent/Guardian #1 Name*

Parent/Guardian #1 Primary Phone*

Parent/Guardian #1 Secondary Phone

Parent/Guardian #1 Email*

Does Parent/Guardian #1 reside at a different address than youth?*

Yes

Parent/Guardian #1 Address

Street Address Address Line 2 City State ZIP Code

Would you like to enter another parent/guardian?*

Yes

Parent/Guardian #2 Name*

Parent/Guardian #2 Primary Phone*

Parent/Guardian #2 Secondary Phone

Parent/Guardian #2 Email*

Does Parent/Guardian #2 reside at a different address than youth?*

Yes

Parent/Guardian #2 Address

Street Address Address Line 2 City State ZIP Code

Youth Medical Info

Allergies*

Please list any allergies the student has. If none, write N/A.

Does the student carry an epi-pen?*

Yes

Other Medical Needs*

Are there any medical problems or medication issues that we should be aware of? If so, please describe. If not, write N/A.

Doctor/Clinic Name*

Doctor/Clinic Phone*

Hospital of Choice*

Insurance Company*

Insurance Company Phone*

Group/Policy Number*

Member ID Number*

Emergency Contact Information

If parent cannot be reached at the numbers above, please list two people that your child can be released to in the event of an emergency.

List*

Phone #

Name

Relationship

Swimming Consent*

CAN swim

CANNOT swim

By checking a box above, I hereby certify that my child:

Electronic Signature and Permissions*

By inputting my initials above, I certify that I understand that my child will be participating in a number of activities which carry with them a certain degree of risk. Some of the activities may include, but are not limited to: swimming, boating, hiking, camping, field trips, sports and other activities which the church may offer. I consent for my child to participate in these activities. I also represent that my child is of adequate health to safely participate in these activities. I also understand and give consent for my child to travel to and from these events in transportation provided by approved volunteer drivers. You are invited to review our driver policy which is available from the applicable youth leader. It is my understanding that the church will attempt to notify me in case of a medical emergency involving my child. If the church cannot reach me, then I authorize the church to hire a doctor or other health-care professional, and I give my permission to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred. I will notify the church if I feel there are any health considerations that would prevent my child’s participation in any activity. I also give my permission for the appropriate ministry leader to restrict my child from participation in any activity which they have any question about for health or other reasons. I hereby release Shoreline Covenant Church from any liability in the event of injury/illness.