DOWNTOWN CHURCH OF CHRIST

YOUTH & FAMILY MINISTRIES

900 N. MAIN

SEARCY, AR 72143

 

 

PARENTAL CONSENT FORM

Subject: Waiver of Liability/Authorization for Medical Treatment of Minor

 

I (we) give my (our) permission for                                                                 to attend the following:

V V                                                                                         V V

I (we) realize that this trip is being offered by the Downtown Church of Christ and will not hold them responsible for accidents.  I (we) give the sponsors on this trip the right to correct and discipline the above mentioned child for behavior we deem inappropriate and in order to promote a good atmosphere for all involved.

            I do hereby authorize adult workers with the Downtown Church of Christ as agents for the undersigned to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis, or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

            Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold harmless any physician, hospital, or other medical center for rendering of such services.

 

 

INSURANCE INFORMATION
 
INSURANCE COMPANY NAME:                                                                                                                                      
POLICY NUMBER:                                                                                                                                                               
POLICY HOLDER (Full Name/Middle In.):                                                                                                                      
SOCIAL SECURITY # OF POLICY HOLDER:                                                                                                                
PLACE OF EMPLOYMENT:                                                                                                                                               
EMPLOYMENT ADDRESS:                                                                                                                                
EMPLOYMENT PHONE:                                                     EMERGENCY PHONE:                                                     
*Any allergies or medical information that needs to be known:                                                                                                                                                                                    
 
Signature of Parent or Guardian:                                                                       Date:                                                    


 
Commitment to Christ
Behavioral Guidelines for Youth Activities

 

 

 

 

Because I (we) understand that the purpose of this youth activity/trip is to serve God and others, I commit myself (my child) to the following:

    I fully agree and commit while on this activity/trip:

1.     Not to use or possess alcoholic beverage(s) of any kind, at any time.

2.    Not to use or possess any illegal substance(s).

3.     Not to use or possess tobacco in any form.

 

If suspicion of any of these occurs, I (we) agree for an adult supervisor to search my person, my room, my luggage, and/or my personal belongings.

 

In order to support the purpose of this trip and to uphold the group goals, I (we) understand that the following consequences will result if I violate the above commitment:

        1. I will be asked to go home, at parents’ expense.

        2. Parents agree to bear expense for child to go home

 

This commitment is intended for the greater good of the group as well as the individual, and is intended to be exercised by all concerned in the spirit of Christ.

 

THIS FORM MUST BE SIGNED BY BOTH PARENT/GUARDIAN AND TEEN.

 

Signature of Parent or Guardian:                                                                 Date:                                   

Signature of Teen:                                                                  Date:                                    

Signature of Teen:                                                                  Date:                                    

 

 
HANDBOOK NAVIGATION
  |  Purpose & Vision  |  Involvement  | 
  |  S.A.L.T. & LIGHT  |  Lifeguards  | 
  |  Educational Program  |  Mission Efforts  |  Expectations & Guidelines  | 
  |  Discipline Policy & Procedures  | 
  |  Sign Up & Expenses Procedures  | 
  |  Blank Permission Form  | 
  |  Event Descriptions  |