Youth Authorization and Health Form 2022

Parents, fill out the top portion with your contact information. The second portion is for your student. Complete one form per minor. If you have any questions, please contact Pastor Corey Gray, Please note this completed form applies for all events though 2022.

*Address Line 1
Address Line 2
*Zip/Postal Code
Please fill out the rest of this form with information about the minor.
*Student First Name:
Student Nickname or Preferred Name:
*Student Last Name:
Address Line 1 (if different):
Address Line 2:
Zip Code:
*Date of Birth:
*Emergency Contact/Relationship:
*Emergency Contact Phone:
Health Care Provider Information
*Insurance Provider:
*Provider Phone:
*Provider Address:
*Provider/Group #:
*Physician's Name:
Physician's Practice Name:
*Physician's Phone:
*Dentist's Name:
Dental Practice Name:
*Dentist's Phone:
*Date of Last Tetanus Shot:
Please record any allergies.:
*Does your child have an EpiPen?:
*Please list all current medications.:
*Please record all medical diagnoses.:
*Are there any special directions for the medical point person?:
Parent/Guardian Consent Form
I acknowledge that my child’s participation in the Fourth Presbyterian Church youth program is voluntary and may require involvement in activities that require traveling or physical exertion. Such activities may include, but are not limited to: outings, retreats, athletic events, competitions, contests, games, local excursions and meetings. I acknowledge that my child’s participation in any Fourth Presbyterian Church youth activity presents risks that my child may suffer property damage, bodily injury, or death. Therefore, in order for my child to be allowed to participate in the above-mentioned activities, I agree to the following: 

I hereby assume the risks of my child participating in all Fourth Presbyterian Church youth activities, and I take the following action for my child, myself, my executors, administrators, heir, next of kin, successors and assigns: A) I waive, release and discharge from any and all claims or liabilities for death or personal injury the following person(s) or entities: Fourth Presbyterian Church, its Pastors, Elders, Employees, volunteers, representatives, subcontractors and agents of any of the above: B) I agree not to sue or bring civil legal action against any of the persons or entities mentioned herein for any claim , liability, injury or damage whatsoever, except in the case of intentional misconduct by Fourth Presbyterian Church, its staff, volunteers, agents or employees and: C) I agree to indemnify and hold harmless all persons and entities described herein from any claims, liabilities, injuries or damages assessed against them as a result of my child’s actions or as a result of any injuries or damages sustained by my child. 

I authorize a leader of the event in which my child is participating to secure emergency medical treatment as deemed necessary by that event leader, including, but not limited to: examination, X-ray, hospital care, hospitalization, injections, anesthesia, surgery and any other emergency medical or dental diagnosis or treatment for my child. I also authorize any licensed physician, emergency, medical technician, hospital or other medical or health care facility to render emergency medical care to my minor child for the purpose of attempting to treat or relieve any injury, illness or other medical problem sustained by my child. I understand that any medical bills that may be incurred will be my responsibility. I consent to the administration of anesthesia as deemed advisable by the emergency medical provider who is rendering care to my child. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical or dental treatment, and I assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact me in the most expeditious manner possible. Permission is also granted to Fourth Presbyterian Church representative(s) to provide the needed first aid or emergency medical care to my child prior to the arrival of trained emergency medical personnel or his or her admission to a medical facility. 

I hereby authorize and give permission for my child to ride in any vehicle while attending and participating in a Fourth Presbyterian Church event if and when designated and directed to do so by a leader of the event. Should it be necessary for my child to return home due to medical reasons, I shall assume all transportation costs. I also acknowledge and agree that any misconduct on the part of my child may also result in he or she being transported home early from an activity at my expense and inconvenience. A student dismissed for a disciplinary reason will not receive a refund of the activity fee. 

I agree that Fourth Presbyterian Church is not responsible for the loss or theft of my child’s personal belongings. 

I authorize agents of Fourth Presbyterian Church to photograph or film my child for use in video presentations or printed publications of Fourth Presbyterian Church ministries including the website. (Your child’s name will not be used in these presentations or publications
By checking the box below, I, as the parent and/or legal guardian of the minor named above, hereby execute this document for and on behalf of this minor and agree to indemnify and hold harmless the person or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Wavier and Release. 
Checkbox 1: