If this is the first time you are submitting a consent form, please complete the form below. Your information will display on the next page in PDF format. You will need Adobe's Reader to print it.

Parental Consent Form
Child's Name:
Address:
Home Phone:
(with Area Code)		 (e.g., 555-123-4567)
I give permission for my child
to attend and participate in
to be held on
at

My child has the following physical condition(s) that may require special attention:
Diabetes Hyperventilation Convulsions Seizures Allergies

Other (please specify):

Does your child require any special accommodations or have special accessibility needs? Yes
Please Explain:
(A youth staff member will contact you to discuss these needs)

Medical Treatment Release and Liability Release
I hereby authorize event staff to obtain and give consent for medical treatment for my child for such injury or illness that may occur during the event, and hereby hold the event staff and their representatives harmless in the exercise of this authority.

I give permission for my child to be transported in vehicles operated by the adults in whose care the minor has been entrusted while attending and participating in this event.

It is my understanding that the above named participant will be covered by my personal medical insurance. The event provides limited/supplemental medical payment coverage for injuries arising out of the event activities which is payable in excess of any other collectible insurance. Payments of any medical injuries not covered by my insurance or the event limited/supplemental medical insurance will be paid by me.
Name of parent/guardian:
Date:
Phone with Area Code: Home: Work: Cell:
Medical Insurance Carrier:
Group Number:
Personal Password: (Use an easily remembered password - to be used for future access)
Signature: _________________________________________________________
  The next screen will display your consent form in PDF format (you will need Adobe's Reader to open the form). You may then print the form, sign it, and return it to the church or Youth Pastor.