Broadway Youth Ministry

Statement of Liability and Parental Release for ANY AND ALL Youth Activities with the Broadway Church of Christ

Parental Consent/Medical Treatment Form

VALID through August 2002

Youth Ministers: Brook & Amanda Roberts

I, the undersigned parent or guardian of                                                                       (SS#:                                       ), a minor, do hereby authorize adult workers with the youth of the above named church to consent to any examination, x‑ray, anesthetic, medical or surgical diagnosis or treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

Further, as parent or guardian of the minor named above, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital or other medical center for rendering such services.

In case of sickness or accident, neither the Broadway Church of Christ nor any individual youth worker shall in any way be held liable for any sickness or accident incurred from the time the group leave Broadway Church of Christ until said group returns to that property. Every possible precaution will be taken by the entity mentioned and individual youth workers to insure good health and to prevent accidents. It should be understood that Broadway Church of Christ will have set rules to protect those on the trip.

Insurance Company or Group:                                         Policy Number:                          

Parent or Guardian:                                                      Home Phone:                             

Address:                                                                    Work Phone:                             

                    ^{Number & Street           City, State              Zip}

In case of emergency, who may we contact as an alternate?

^{Name                 Number & Street                  City, State                 zip                                     Phone(s)}

Family Physician                                                   Phone:                       

CONDUCT OF THE PARTICIPANT: The participant agrees to conduct himself/herself in such a way that is becoming of Christian principles and behavior at all times. Any and all behavior problems that arise are subject to disciplinary action.

Being in agreement with and accepting the above stated policies, I the parent/guardian assume all responsibility for him/her during the trip.

Signature of Parent or Guardian                              Date                 

Are there any special medical conditions we should be aware of?                                

Allergies:                                             Medical Disorders:                                             

Blood Type (if known):                           Other:                                                            

Medications:                                                                                                             

(The nurse must administer ALL prescription meds. They MUST be in the original container labeled by the pharmacy.)