Youth Consent From 2018/2019

Souderton Mennonite Church, 2018-2019 School Year

Child/Youth Name (Last, First, Middle) *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Age *
Birthday
*
Mother's (Guardian's) Name *
Cell Phone (Mother) * - (###) - ### ####
Work Phone (Mother) - (###) - ### ####
Email (Mother)
Father's (Guardian's) Name
Cell Phone (Father) - (###) - ### ####
Work Phone (Father) - (###) - ### ####
Email Father
I/we give consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of my child during the event to be used, distributed or shown as SMC sees fit. * YES NO
Parental Consent
This form is valid for the current school year, September 2018 through August 2019, and must be updated annually. If there are any changes in your child's medical care provision or needs, please contact Jessica Gillespie immediately.

I/we give permission for our child named above to participate in all church-sponsored activities on the church premises, and trips/activities away from the church premises throughout the current school year. I/we understand that I/we willbe given prior notice of all trips away from the church premises. I/we further understand that I/we may revoke permission for a specific activity or trip at any time.

Although the church desires to provide a safe and enjoyable time for all children and youth, accidents can still happen. I/we understand that there are risks/dangers involved both on campus and off campus. I/we agree to assume responsibility for those risks/dangers associated with the travel and activities. I/we agree to hold harmless Souderton Mennonite Church (SMC), its emplopyees and representatives, including volunteers and drivers, from any and all claims arising from my child's participation. This release agreement does not apply to claims of intentional misconduct by the church, its employees or volunteers.

In case of an accident, illness, or other emergency, I/we request that SMC contact me/us. If SMC cannot reach me/us after conscientious effort, I/we give permission for the church staff to call paramedics immediately and then contact me/us as soon as possible thereafter.

I/we authorize and consent to any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care, which, in the best judgment of a licensed physician or dentist is deemed advisable. I/we agree to assume the financial responsibility for expenses incurred as a result of those services being provided. I/we also agree to be financially responsible for emergency medical transportation. In cases where medical care is needed, but the situation is not an emergency, SMC will make every effort to contact the parents/guardians before treatment is given.

Parent/Guardian Signature *

please type in your name here
Medical Information for Child/Youth
Do you have Medical Insurance? Yes No
Name of Insured
Insurance Company
Insurance Policy #
Physician
Physician's Phone - (###) - ### ####
Dentist
Dentist's Phone
- (###) - ### ####
List any allergies (food, medicine, etc) and severity of reaction.
List any other important information we need to be aware of (i.e., physical limitations, fears, special needs)
List all medications being taken. (Medications must be given to trip coordinator in original prescription bottle for all off-campus activities and trips.)
I/we give permission for trip leaders to administer:
Ibuprofen Acetaminophen Nothing is to be administered to my child.
Emergency Contact, if we cannot reach you: First Last
Emergency Contact's Phone
- (###) - ### ####
Comments:

Youth Consent From 2018/2019

Youth Consent From 2018/2019

Medical Information for Child/Youth