Blue Mountain Church
Youth Waiver Form

Student Name

First Name

Last Name

Date of Birth

YYYY

Grade for 2022/23

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Health Card #

Doctor's Name

Doctor's Phone

(###)

###

####

Medical Insurance Company

Policy #

Mother's Name

First Name

Last Name

Mother's Cell Phone

(###)

###

####

Father's Name

First Name

Last Name

Father's Cell Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

For your child's safety and our knowledge, is your student a:

Does your child have any allergies?

Does your child have any other health history or concerns we should be aware of?

Date of last Tetanus shot:

Should this child's activities be restricted for any reason? Please explain:

Throughout the year, pictures will be taken at events and activities. I grant permission to the Youth Ministry program and Blue Mountain Church to use pictures that include my son/daughter for promotional purposes (slide shows, wall postings, social media, etc.) and/or on the Focus Youth social media

Yes

This consent form gives permission to seek whatever medical attention is deemed necessary and releases the church and its staff from any liability against personal losses of named child. This consent also gives permission for named child to be driven during activities and events by staff and youth leaders. I/We the undersigned have legal custody of the student named above, a minor, and have given our consent for him/her to attend events being organized by the church. I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child's involvement. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named above. I/We also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the student ministries staff member.

Parent/guardian name:

Date

YYYY

For your information, we expect each student to conform to these rules of conduct:

-No possession or use of alcohol, drugs, or tobacco
-No fighting, weapons, fireworks, or explosives
-No offensive or immodest clothing
-Participation with the group is expected
-Respect property
-Respect one another, staff, and adult leaders
-Respect and comply with event schedules

Students who fail to comply with these expectations may be sent home and/or excluded from further youth nights/events.

Blue Mountain ChurchYouth Waiver Form

Office Hours: Mondays-Thursdays, 9:00am-3:00pm

Blue Mountain Church
Youth Waiver Form