YOUTH MINISTRY RELEASE FORM

YOUTH INFORMATION

Youth: Name

Youth: Date of Birth

Grade Entering Fall: 2024

Youth: Gender

Male Female

Youth: Address

Youth Email

Youth Cell Phone

PARENT / GUARDIAN INFORMATION

Parent or Guardian Name

Parent or Guardian Email

This address will receive a confirmation email

Parent or Guardian Address IF different from Youth

Parent or Guardian's Mobile Phone

Emergency Contact Name

Relationship to the Youth Member

Emergency Contact Phone #

MEDICAL INFORMATION

Physician's Name

Physician's Phone #

HEALTH HISTORY

(To be completed by parent or guardian.)

Check if Youth has been treated for any of the following: treated for Allergies Asthma Diabetes Other

If allergies, please list:

If "other" please explain:

Please list any medications your child would be using at Youth events (medications must be in prescribed bottles):

Please list any restrictions, physical activities or concerns you may have:

PHOTO RELEASE FORM

Do you authorize the use of photos or videos or the likeness of your child?

Yes No

AUTHORIZATION MUST BE SIGNED BY PARENT/GUARDIAN FOR ALL YOUTH UNDER THE AGE OF 18.

My child has permission to take part in all STJDCC church activities, including offsite activities under supervision, and I agree that the church, or its personnel, will not be held responsible for accidents or personal injury arising therefrom. In the case of a medical emergency, I understand that every effort will be made to contact the parents or guardians of the participant. In the event I cannot be reached I hereby give permission to the medical examiner selected by the St. Johns DCC staff to hospitalize, to secure proper treatment for, to order an injection, anesthesia, or surgery for my child as named on this form. I understand that St. Johns DCC does not provide medical insurance.

By typing your full name here, you are giving consent:

Today's Date:

Description

A completed Youth Ministry Release Form must be on file for every youth under the age of 18 before participating in ministry related activities. Please complete one form per student. This form will be in effect for programming taking place June 1, 2024, to December 31, 2024.

Please note: if you have any significant changes in this timeframe (new doctor, phone #, change of address, etc.), an updated form will need to be submitted.

Thank you!

YOUTH MINISTRY RELEASE FORM

Description

Please Fix the Following