Youth Personal Information & Permission and Liability Release

This form has two purposes.
Authorization and Medical Consent Form
1. Collect information to connect with your child.
2. Permission & Liability form.

The Youth Elders, Leaders and Youth Communications Co-ordinator would like to communicate directly with your teen, letting them know about up coming events.

In order to ensure your teen's safety while under our supervision we ask that you complete the permission and liability information each year.

As information may vary, please complete one form for each teen in your household who may attend either Teen Club or Impact at any point this year.

Information received is confidential and is being gathered for the purposes of serving your child while in the care of Community Christina Reformed Church. Any medical information collected here serves to authorize CCRC, its staff and volunteers, to obtain medical assistance in emergencies

Participant Information (your teen's information).

Student Name

Student Email

Student Phone #

Student Home Address

Birth date of person attending Teen Club or Impact

Current Grade

7 8 9 10 11 12

Agreement to communicate directly

By clicking this box I accept and acknowledge that Community CRC will use this data to contact my child directly about activities and planned events for Teen Club or Impact By clicking this box I permit the CCRC staff and youth ministry volunteers to communicate with my child via social media if and when applicable All communication for meetings and events must be communicated to my contact information only

Parent/Guardian Information

First Name

Last Name

Parent/Guardian perferred phone #

This address will receive a confirmation email

Home Address (you can type "same as above")

Emergency Contact Information

Emergency Contact

Phone # of Emergency Contact

Relationship to participant

Family Physician

Physician Phone

Health Card Number

Does this participant have any allergies or medical conditions?

If yes, please explain or if No type N/A

Should this participant be restricted from any activities?

If yes please explain or if No type N/A

Abuse Prevention Policy Agreement

I will comply with the Community Christian Reformed Church Abuse Prevention Policy regarding prompt pick-up of participants:

“Participants should be picked up within 15 minutes of the end of any activity.” In accordance with the policy, “If not picked up within 10 minutes, a Volunteer/leader will telephone the Parent(s)/Legal Guardian to ensure someone is coming to pick up the participant.”

By selecting Yes you are agreeing to comply with the Abuse Prevention Policy referred to above.

Yes No

Medical Release “In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and or order an injection, anesthesia, or surgery for my child if deemed necessary.”

Yes No

Liability Release

“In consideration for acceptance for participating in the activities of Community Christian Reformed Church of Kitchener youth ministry programs, I release, forever discharge, and agree to hold harmless Community Christian Reformed Church of Kitchener and it’s staff, council, members, committees, program leaders, volunteers, employees, and agents from any and all claims, demands, or liability for sickness, personal injury, or death as well as property damages or loss and expense of any nature, incurred during participating in the activities of Community Christian Reformed Church of Kitchener or during procurement or execution of authorized medical or dental treatment. I assume all risk for sickness, personal injury, death, damage, loss, and hereby give to Community Christian Reformed Church of Kitchener to furnish any necessary transportation, food, and lodging for the participant. Should it be necessary for the participant to return home due to any medical reasons, disciplinary actions or otherwise, I hereby assume all costs.”

By selecting Yes you are digitally signing that you agree to the Liability release above.

Yes

By selecting Yes, you are giving Community Christian Reformed Church permission to transport your child as events and programs require.

Yes No

Photo Release I give Community Christian Reformed Church the permission to photograph my child and use his or her picture solely for the church’s website or social media platforms.

Yes No

Electronic Signature

By entering my name in the above box, I am providing my digital signature to this form.

Thank you for completing and submitting the form.

Youth Personal Information & Permission and Liability Release

Description

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