Youth Ministries Parental Release Form

I, the undersigned, being the parent / legal guardian of the minor child named below, do hereby give permission for my child to participate in Youth Group Events through Christ Presbyterian Church.

I certify that I am cognizant of the inherent dangers associated with participating in the activity; that there is some element of risk in participation and that the activity may take place off and on church property. To this end I agree that neither Christ Presbyterian Church, its elders, representatives, instructors, agents, nor chaperones will be held liable for any injury or illness, which may result in harm or other damages.

I authorize Christ Presbyterian Church and its representatives to render or obtain such emergency medical care / treatment as may be necessary should injury, harm or accident occur to my child while participating in this project.
I further state that I am of lawful age, legally competent, and the legal parent / guardian of the below noted child. I understand the terms noted herein are contractual and are not merely recital, and that I have signed this document of my own free act and volition. I further state and acknowledge that I have fully informed myself of the contents of this affirmation and release by reading it before I have signed it.

*

Youth first name:

*

Youth last name:

*

Home phone:

*

Home street address:

*

Home city:

*

Father's name:

Father's cell phone:

*

Mother's name:

Mother's cell phone:

*

Medical Insurance Company:

*

Medical policy number:

*

Name of emergency contact person:

*

Phone number of emergency contact person:

*

Important medical information (examples: medications, allergies, physical limitations)  If no significant medical information exists, please type the word "None".

*

Date this affirmation is submitted:

* Email Address: