Parental Consent Form

Child's Name

Grade

School Child Atttends

Date of Birth

Address

PARENT/GUARDIAN INFORMATION

Primary Contact Name

Email

Phone

Alternate Contact Name

Phone

Email

Emergency Contact Name

Emergency Contact Phone

YOUTH CONTACT INFORMATION (7-12TH GRADE)

Youth Cell Phone

Youth Email

Youth Facebook Address

MEDICAL INFORMATION

Primary Care Physician

Primary Care Physician Phone

Practice Name

Date of Last Tetanus Shot

Insurance Company

Phone

Policy/Group Number

Policyholder's Name

Medications
List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.

Over the Counter Medication Permission
Do you give permission for your child/youth to be given over-the-counter medication as needed and as directed on the label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomachache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a Calvary youth event?

Yes - I give permission for an adult leader to give my child approved over-the-counter medications as directed on the package to treat non-emergency medical situations.‎ No - Contact me or get medical help if my child has minor medical concerns.‎

Please list any other medical conditions your child may have or share other pertinent information about the participant ( i.e., physical, behavioral or emotional) that would be important for us to know.

Photo Release Consent

I agree to the photo release consent.

Terms of Service

I agree to the terms of service.

Digital signature
Use your mouse as a pen and sign in the box.

Clear