Parent/Guardian Consent/Release of all Claims/Medical Information Form

Please turn in or email (micah@fefcyouth.com) to Micah Salmon, Director of Youth Ministries.

If you have any questions, please call Micah at 964-4251 (cell)

This form covers all First Evangelical Free Church of Colorado Springs youth trips/activities/programs/events during the current year of: __________:

To Whom It May Concern: I (parents/guardians name) ______________________________, parent or guardian of (students name) ______________________________ do hereby allow the named child to attend any and/or all youth group activities during 2003 that I deem appropriate.  I understand that my child’s participation in any trip/activity/program/event indicates my decision to allow his/her involvement therein.  I agree and consent to have the staff members, leaders and/or counselors, under whose auspices the program is conducted, and any other worker in the program approved as parent to secure any emergency medical care or treatment that may be necessary for my child during any and all trips/activities/programs/events, including transportation to and from any and all destinations.  I further assume all responsibility for the decisions so made, and the emergency care or treatment so secured by and/or for my child.  Should I, the participant, be 18 years of age or older, I hereby agree to all of the above concerning myself.

I being 18 years of age or older, do for myself (and on behalf of my child, if said child is not 18 years of age or older), hereby release, forever discharge and agree to hold harmless First Evangelical Free Church of Colorado Springs and the directors thereof, from any liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever, which may be incurred by the undersigned and/or the child and/or that may occur while said child is participating in any youth group activity.

Furthermore, I (and on behalf of my child if under the age of 18 years) hereby assume all risk of personal injury, sickness, death, or damage as a result of participation in any activities involved therein.

The undersigned further hereby agree to indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant.

(If the participant has not attained the age of 18 years:)

I am the parent or legal guardian of this participant, and hereby grant my permission for him/her to participate fully in said trips/activities/programs/events, and hereby give my permission to take said participant to a doctor or hospital and hereby authorize medical treatment, and assume the responsibility of all medical bills, if any.  Further, should it be necessary for the participant to return home due to disciplinary action, for medical or otherwise, I hereby assume all transportation costs.

(Only participant need sign if 18 years of age or older, however, participant must sign regardless of age)

Participant’s signature_________________________, Participant’s Birth date________, Age____, Grade____

Parent/Guardian Signature ______________________________ Relationship to participant_______________

Home Address _________________________________________________________________________________

Telephone (daytime) _______________ (Evening) ______________ (Cell) _____________________

Emergency contact (name)  ______________________________ Telephone _______________

Do you carry medical/hospital insurance?__________ (If yes, continue below.  If no, leave below blank.)

Name of insurance company ______________________________ Policy or group # ___________________

Does the participant have any medical condition(s) that any medical professional or we should be aware of?  If so, please list them here: _____________________________________________________________________________________