Parental Consent, Certification, and Medical Authorization

Parents and legal guardians of minor children (under age 18) are asked to complete this form and return it
to the church. The information requested is designed to assist the church in providing for the safety of
minors during church sponsored activities.

GENERAL INFORMATION (please print)

Youth’s Name___________________________________________Date of Birth___________________

Father’s Name___________________________________Mother’s Name_________________________
Youth’s Address_______________________________________________________________________
Home Phone No.__________________________________Parent’s Work Phone No.________________
Emergency Phone No._______________________________
Family Doctor_____________________________________Phone No.___________________________
Health Insurance Plan/Number____________________________________________________________

GENERAL RELEASE/HOLD HARMLESS AGREEMENT

As the parent or legal guardian of the above student, I agree to the following:

1. DESIRE- The student above desires to participate in the program, events, or activities (hereinafter
collectively referred to as “activities”) operated or sponsored by The Bible Fellowship Church of
Royersford (hereinafter referred to as the “Church”) and its youth ministry.

2. POSSIBILITY OF INJURY – The student above may incur personal injury or bodily damage while
participating in such Activities.

3. NECESSITY OF PERMISSION FORM - The student above cannot participate in such Activities
without releasing and holding harmless the Church and the youth ministry.

4. GENERAL RELEASE AND DISCHARGE – I, the undersigned, request that the Church and its
youth ministry allow the student to participate in the Activities and in consideration thereof agree to
hereby release, and forever discharge the Church, its youth ministry, the youth director, its officers, and
any parties volunteering on behalf of the Church or its youth ministry from all action, claims, damages,
costs, expenses, or damages of any kind growing out of or related to the Activities.

5. RELEASE FOR INJURY AND DAMAGES - I acknowledge that this is a full and complete release
for all injuries and damages which the student may sustain as a result of participating in the Activities.

6. TREATMENT FOR INJURY – I authorize the treatment of the student by a qualified and licensed
medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may
endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, while
said minor is participating in the Activities, including transportation to and from the site. This authority is
granted only after a reasonable attempt has been made to contact me, the parent/guardian. I understand
that the Church will not be responsible for medical expenses incurred, but that such expenses will be my
responsibility as parent/guardian.
MEDICAL QUESTIONNAIRE

1. Is your child presently being treated for an injury or sickness or taking any form of medication for any
reason? Yes____ No____ (if yes, please explain)_____________________________________________
_____________________________________________________________________________________

2. Is your child allergic to any type of medication? Yes____ No____ (if yes, please explain)___________
_____________________________________________________________________________________

3. Does your child require a special diet? Yes____ No____ (if yes, please explain)__________________
_____________________________________________________________________________________________

4. Does your child have (or has ever had) any of the following: (circle, and please explain below)

Seizure disorders Asthma Heart murmur/disease

Diabetes Hay Fever
_____________________________________________________________________________________
_____________________________________________________________________________________

5. Does your child have any allergies other than medical? Yes____ No____ (if yes, please explain)_____
_____________________________________________________________________________________

6. Does your child ever sleep walk? Yes____ No____

7. Can your child swim? Yes____ No____

8. Does your child have any physical handicap or illness which would prevent him/her from participating
in normal rigorous activity? Yes____ No____ (if yes, please explain)_____________________________
_____________________________________________________________________________________

9. Is there any specific type of activity that you do not want your child to participate in? Yes____
No____ (if yes, please explain)____________________________________________________________
_____________________________________________________________________________________

I agree to notify the Church in the event of any health changes which would restrict my child’s
participation in any normal youth or children’s activities. I also understand that the adult supervisors
reserve the right to restrict my child from any activity that they do not feel is within the physical
capabilities of my child.

PARENTAL/GUARDIAN CONSENT

Being the parent or legal guardian of the student named above, I give my consent to the participation of
my child in all of the scheduled activities of the youth group of The Bible Fellowship Church of
Royersford, Royersford, PA, including field trips, campouts, swimming, boating, hiking, sporting events,
and any other activities customarily associated with a church youth group. Further, I certify that my child
is physically fit and adequately trained to participate in such events, including swimming, (except as
noted in 8 and 9 above).

___________________________________ ___________________
(Signature of Parent/Guardian) (Date)