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Firstmtdora.org

First Baptist Church Mount Dora, FL
INSTRUCTIONS: Please print
Youth Ministry Program (Youth Grade 7-12)
legibly in ink and complete front
Medical Release and Parental Consent Form and back of this form. All
*** Form is legal for 18 months from date not
signatures must be notarized.
YOUTH INFORMATION
PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION
If parents are divorced or separated, who has legal custody?
relative or friend to notify in case of an emergency and we cannot MEDICAL INFORMATION
Name of Youth as Listed on Medical Insurance: Name of Secondary Insurance Company (if applicable): YOUTH MEDICAL HISTORY
Check medicines that can be
given your child
Does your child wear  glasses  contact le Benadryl Rate this child's general health:  Excellent  Good  Fair  Poor Is this child currently under a physician's care for any illness?  Yes  No Should your child's activities be restricted for any reason?  Please check the best description of your child's swimming ability:  good swimmer  fair swimmer  non-swimmer Does this child have any allergies to any of the following:  pollens  medications  food  insect bites  other If so, please explain: Describe in detail the nature and severity of any allergies, physical and/or psychological ailment, illness, propensity, weakness, limitation, handicap, disability, or other special medical condition(s) to which your child is subject and of which the staff/volunteers of the Church should be aware, and what, if any, action of protection is required on account thereof. If more room is needed, please submit additional information in writing and attach it to this form THIS IS A MEDICAL RELEASE/PARENTAL CONSENT: ONLY A WRITTEN NOTICE WILL NULLIFY THIS FORM
THIS IS A MEDICAL RELEASE/PARENTAL CONSENT: ONLY A WRITTEN NOTICE WILL NULLIFY THIS FORM
Does this child suffer from, or ever experienced, or is being treated currently for any of the following (if checked, please explain below): Please list and explain any major illnesses and/or hospitalizations this child experienced during the last year.
EXPECTATIONS OF YOUTH
We expect each youth and youth sponsor/chaperone to conform to these rules of conduct:
* No CDs, DVDs, IPODs, radios, headphones, mp3 players, computers.
* No students can drive.
* No possession or use of alcohol, drugs, or tobacco.
* No fighting, weapons, fireworks, lighters, or explosives.
* Respect property. Respect one another, staff, and adult leaders/sponsors/chaperones.
* No boys in girls' sleeping quarters and no girls in boys' sleeping quarters.
* Participation with the group is expected. Respect and comply with event schedules.
* No offensive or immodest clothing. ONE PIECE BATHING SUITS FOR GIRLS.
I, the youth/student/child listed on this form, have read the rules of conduct, Student Signature
the evaluation of my health, and permission to participate in the Youth/Student Ministry group activities. I agree to abide by the stated personal limitations and rules of conduct.
YOUTH WHO FAIL TO COMPLY WITH THESE EXPECTATIONS MAY BE SENT HOME AT THEIR PARENTS' EXPENSE
MEDICAL RELEASE / PARENTAL CONSENT: (ONLY A WRITTEN NOTICE WILL NULLIFY THIS FORM)
Activities, retreats and trips may include, but are not limited to: amusement parks, baseball, basketball, Bible studies, biking, boating, bowling,
broomball, canoeing, camping, cookouts, concerts, downhill skiing, DNOW, go carts, going out to eat, golfing, football, 5th quarters, games in
the park, hayrides, hiking, ice skating, laser tag, malls, miniature golf, mud volleyball, river rafting, roller-skating/blading, softball,
snowboarding, slip-n-slides, soccer, summer camp, swimming, volleyball, water sports, etc. Note to Parents: If you desire to limit your
child's participating in any event, please submit your wishes in writing to the Church Youth Pastor prior to that event.
As the parent (or legal guardian), I the undersigned, certify that my child, named in this Annual Medical Release and Parental Consent Form,
has my express permission to participate in all activities, of any nature, sponsored by the Church for the Church year as indicated at the top of
this form. If I desire to limit my child's participation in any event, I understand I must submit my wishes in writing to the Church Youth Pastor
prior to that event. I also give my permission for the Church leaders to restrict my child from participating in any activity which they have any
question about for health or other reasons. I also give permission for my child to ride in any vehicle designated by the adult in whose care my
child has been entrusted while attending and participating in all activities sponsored by the Church. I understand that there are inherent risks
involved in any ministry or athletic event and knowing that the Church will always try to act responsibly, I fully release the Church, its pastors,
employees, and volunteer workers/chaperones/sponsors from any and all liability for any claim, including, but not limited to injury, loss, or
damage to person or property that may occur during the course of my child's involvement.
It is my understanding that the Church will attempt to notify me in case of a medical emergency involving my child. In the event that my child
is injured and requires the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician.
In the event treatment is required from a physician and/or hospital personnel designated by the Church, I agree to hold such person free and
harmless of any claims, demands, or suits for damages arising from the giving of such consent. I also acknowledge that I will be ultimately
responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further,
I affirm that the health insurance information provided above is accurate at this date and will, to the best of my knowledge, still be in force for
the child named above. I also agree to bring my child home at my own expense should he/she become ill or if deemed necessary by the
Youth/Student Ministries staff member(s). By signing this document I also acknowledge that my child's photographs may be used in
any responsible

NOTARIZATION - SIGNATURE MUST BE IN THE PRESENCE OF THE NOTARY
Parent/Guardian Signature:
_____________________________ ate:__________________
(Signature must be in the presence of the notary) Parent/Guardian Signature: _____________________________Date: _________________
(Signature must be in the presence of the notary) State of Alabama, County of _______________________ Sworn to and subscribed before me on this ________ day of __________________________, 20___ Notary Public ___________________________________ My Commission Expires: _________________________ THIS IS A MEDICAL RELEASE/PARENTAL CONSENT: ONLY A WRITTEN NOTICE WILL NULLIFY THIS FORM

Source: http://www.firstmtdora.org/youth/FBC_MD_Medical_Release.pdf

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