8370 Youth Event Waiver

Please fill out the form below for All Youth Events!

Please note that the information on this form is for the use of the youth leaders at Crow Hill Bible Church and is not available to any other individuals or groups. This means that we will not disclose your e-mail address, mobile number or any other details to another individual without your permission. The information and permissions will be considered valid unless written notice from parent or legal guardian is received. If any information below changes you are responsible for informing Crow Hill of those changes.

Youth Name

First Name

Last Name

Birth Date

YYYY

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Parent Cell Phone

(###)

###

####

Medical Information

Is your youth presently being treated for an injury, sickness, or taking any medication?

Yes

If yes, explain:

Are there any medical conditions (i.e. allergies, asthma, epilepsy, diabetes, travel sickness, etc.) which we should be aware of?

Please list any details of special dietary needs we should be aware of (i.e. food allergies)

Emergency Contact Details

In the event of an emergency relating to your son/daughter please provide the information below which we can use to contact you. I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of 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 or a health care provider: Jared Miller, or another adult chaperone designated by the pastor, and I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that Crow Hill Bible Church or their staff 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.

Primary Adult Emergency Contact

First Name

Last Name

Phone 2

(###)

###

####

Secondary Adult Emergency Contact

First Name

Last Name

Phone 3

(###)

###

####

Media Usage

We have a Facebook, Twitter, and Instagram page which may be used to contact Crow Hill Bible Church about events related to 8370 Youth. This account is not used after 10pm and all conversations on it are logged.

Agreements

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of Crow Hill Bible Church, and any other supervised activities customarily associated with its youth group. 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. I agree to my son/daughter participating in 8370 Youth activities run by the team. I understand that every care will be taken to ensure the health, safety and welfare of my child. I realize and accept that in the event of my child’s behavior adversely affecting the safety of the activity, the organizers reserve the right to return my child home.

Electronic Signature