JGen Activities Parent Consent

This consent form only need to be filled out once per year and is good from September 1st through August 31st of the next year.

Parent Name

Student #1

Name of Youth

Is your youth presently being treated for an injury or sickness or taking any medication?

Yes No

If yes, please explain.

Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.)

Asthma Diabetes Hay Fever Heart Murmur Kidney Disease Seizure Disorders None

If yes, please explain.

Does your youth ever sleepwalk?

Yes No

Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity?

Yes No

If yes, please explain.

Student #2

Name of Youth

Is your youth presently being treated for an injury or sickness or taking any medication? Yes No

If yes, please explain.

Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.) Asthma Hay Fever Kidney Disease Diabetes Heart Murmur Seizure Disorders None

If yes, please explain.

Does your youth ever sleepwalk? Yes No

Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity? Yes No

If yes, please explain.

Student #3

Name of Youth

Is your youth presently being treated for an injury or sickness or taking any medication? Yes No

If yes, please explain.

Does your youth have, or has your youth ever had, any of the following? (Please check all that apply.) Asthma Hay Fever Kidney Disease Diabetes Heart Murmur Seizure Disorders None

If yes, please explain.

Does your youth ever sleepwalk? Yes No

Does your youth have a physical handicap or illness that would prevent him or her from participating in normal rigorous activity? Yes No

If yes, please explain.

Doctor/Insurance Information

Family Doctor

Doctor's Phone

Insurance Company

Policy Number

Consent and Certification

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of NEWDAY CHURCH and any other supervised activities customarily associated with its youth group, including youth rallies, overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.

I agree I do not agree

Medical Treatment and Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize and give permission to NewDay Church staff in providing of necessary medical services in the event that my youth is injured or becomes ill. I understand NewDay Church will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the youth director in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the youth leaders and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth.

I agree I do not agree

JGen Activities Parent Consent

Description

Please Fix the Following