Grow Student — TC First Assembly

Ages 12-18

Meeting

Wednesdays 7:00-8:00pm

Sundays 9:30-10:30am

Youth Activity Consent Below

Parent or Legal Guardian Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Phone

(###)

###

####

Youth Name

First Name

Last Name

Youth Age

Youth's Birthday

MM

DD

YYYY

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

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

Siezures

Kidney Disease

Other

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?

If yes, please explain:

Doctor's name and contact info:

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 Texas City First Assembly of God Church, and any other supervised activities customarily associated with its youth group, including youth outings and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing. 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 the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth, if required by law or a health care provider: Pastor Robert Zahirniak, or another adult chaperone designated by the pastor. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that these persons 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 leader 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.

Parent's Signature

Location

Contact