Youth Name *

First Name

Last Name

Youth Phone

(###)

###

####

Youth Date of Birth *

MM

DD

YYYY

Youth Grade in the Fall of 2023 *

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Parent Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

MEDICAL RELEASE: As a parent/guardian, I give my permission for the registered minor to attend Youth Group activities. I authorize treatment under the direction of any licensed physician of the registered minor in the event of a medical emergency which in the opinion of the attending physician may endanger his or her life or cause disfigurement, physical impairment or discomfort if delayed. This authority is granted after reasonable effort has been made to reach me by phone. I will not hold the church, or their staff, administration, or volunteers, liable for any injury to or loss of possessions by the registered minor during any activity on the church property. *

YES, I give permission as stated above for my child(ren) regarding medical care

NO, I do NOT give permission for my child(ren) to receive medical care