Personal/Medical Information

All About You!

Your Name Phone Number

Address with city and zip

Date of Birth Email Address

School Expected year of Social Security Number High School graduation

Parent/Guardian Information

Parent/Guardian #1 Home Phone

Cell Phone (If applicable) Work Phone (If applicable)

Parent/Guardian #2 Home Phone

Cell Phone (If applicable) Work Phone (If applicable)

Emergency Contact #1 Phone

Emergency Contact #2 Phone

Medical info

Physician’s Name Physician’s Phone

Allergies (including but not exclusively medications) Last Tetanus

Special Medical Conditions or Physical Handicaps

Medical Insurance Company Policy/Group # Member’s Name/ID #

etcetera youth medical release and info form 160 West Hamlin ! Rochester Hills ! MI ! 48307 ! 248.651.3537

jason@faith-epc.org

This form is to be filled out by both the youth and the youth’s parent or legal guardian. All information is confidential and will remain on file in the …etc offices through September 10, 2016. It is the parent(s)/youth’s responsibility to make sure that the …etc offices are updated in the case of any changes.

Youth’s Signature

I, , wish to attend events and trips associated with …etc, the youth ministries of Faith Church. I understand that the events/trips are a ministry to proclaim Jesus Christ as Lord and Savior. My attendance will enable me to learn more about Him, enjoy the company of other youth, and enjoy the activities involved. In keeping with this spirit, I promise to obey the instructions of the youth leaders and the rules that are set in place for the event, respect the rights of others and not to bring or use any non-prescribed drugs, narcotics, tobacco or alcoholic beverages. I acknowledge that no knives or weapons of any nature are allowed as well. I am aware that I may be sent home at my parent’s expense prior to the expiration of this event if any of those promises are violates. I also understand that iPods, cell phones and other electronic entertainment devices are not allowed unless previously specified by the youth minister. If they are brought, I understand I may lose them permanently. I agree to do nothing that would willfully or otherwise hinder or prohibit others ability to enjoy the trip/event. In accordance to that I will dress appropriately and not bring along any clothing, movies, songs, magazines or the like that would be offensive or contrary to the goals of …etc.

Signature of youth Date

Parent/Guardian’s Signature

I, , give permission for the above-mentioned youth to join …etc, the youth ministries of Faith Church. I understand that if he/she is sent home early because of violation of the above promise, or for any other reason that the youth minister, or staff, sees as appropriate reason for dismissal, it will be at my expense. I hereby authorize …etc, the youth ministries of Faith Church, its staff, leaders or adult sponsors as agent for the above signed minor to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis, or treatment and hospital care or service, which is deemed advisable and is to be rendered to said minor, under the general or specific supervision of any physician and surgeon licensed, or the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care which the treating health care professional, in the exercise of their best judgment, may deem advisable to protect the life and health of said minor. I also allow my child’s photo to be used on websites and social media that are used to promote church activities and for in -house slide shows. I agree to defend and indemnify Faith Evangelical Presbyterian Church, it’s employees and volunteers against any claim or action that might arise on behalf of myself or my son/daughter other than the willful, wanton, or reckless misconduct of Faith Evangelical Presbyterian Church, it’s employees, session or volunteers. This authorization is given, and shall remain effective from September 16, 2015 to September 10, 2016 unless sooner revoked in writing and delivered to …etc, the youth ministries of Faith Church.

Signature of Parent/Legal Guardian Date

Please note that we need to be notified of ANY medications that your youth will need to bring on an event, PRIOR to the event. The responsibility of notifying us rests with you.