Youth Liability and Release Form Youth Liability and Release Form Please enable JavaScript in your browser to complete this form.Student's Name *FirstLastStudent's Birthdate *Student's Street Address *Student's Phone Number *Student's Social Security Number *Parent/Guardian's Name *FirstLastParent/Guardian's Phone Number *Alternate Emergency Contact *FirstLastAlternate Emergency Contact Phone Number *HEALTH HISTORY – Allergies & Other Conditions *Insect AllergyHeart ConditionOther AllergyEpilepsyDiabetesAsthmaDrug AllergiesHay FeverFrequent Upset StomachNoneIf you checked any of the above, please provide details (i.e., include normal treatment of allergic reaction)Date of Last Tetanus Shot *Name and dosage of any medications that must be takenOur church’s insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related active activity. Do you have health insurance? * “In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthetic, or surgery for my son or daughter as deemed necessary.” If “yes,” Insurance Company NameYesNoInsurance Policy NumberInsurance Company AddressLiability Release: The undersigned, is the parent or legal guardian of, a student in attendance at functions of Pinecrest ARP Church, and does hereby grant permission for said student to participate in all activities, trips, and programs in connection with Pinecrest ARP Church. I hereby acknowledge that my student is physically fit and capable of participating in all such activities. Transportation arrangements will be made under authorization of Pinecrest ARP Church and the trip will be under adult supervision. Since the activity, trip, or program is arranged for the benefit of the participants, it is understood that Pinecrest ARP Church, its employees, and adult supervisors will exercise caution, judgment, and care, but cannot and will not be held responsible in case of accident, injury, and loss or damage of property in connection with the activity, trip, or program, and the undersigned does hereby release, acquit and save them harmless from all such claims. The undersigned further agrees to admonish the student participant to exercise care, to be well behaved, and in all things obedient to and under the direction and control of those adults in charge. *Read and AgreedParent/Guardian's Digital Signature *FirstLastToday's Date *Student/Parent Agreement: On any trip sponsored by Pinecrest ARP Church, drugs, alcohol and/or any tobacco products, also weapons of any sort (i.e., knives, guns) will not be permitted. If in the event that any students are found in possession or under the influence of any of the above, he/she will be sent home at the expense of the parents – either by the parent coming to pick up the student or expenses paid for any other transportation. I, the undersigned, agree to comply with all the rules and policies stated by Pinecrest ARP Church and understand the penalties for any violation committed by the student. As the parent or guardian, I agree that I have all responsibility to pick up my student or pay any transportation in the event that he/she is sent home. *AgreedStudent's Digital Signature *FirstLastParent/Guardian's Digital Signature *FirstLastToday's Date *PHOTO RELEASE: I hereby give permission for photographs and/or video footage of my son/daughter to be used in youth materials and/or publications and in materials by Pinecrest ARP Church and the Associate Reformed Presbyterian Church. I understand that at no time will my son/daughter be identified by name on any website run by Pinecrest ARP Church. I understand that Pinecrest ARP Church will make every effort to see that the safety and privacy of the person named above is maintained at all times. *Read and AgreedPlease do not use photographs and/or videos of my student.Parent/Guardian's Digital Signature *FirstLastToday's Date *Submit
