Name of child/youth: _____________________________________________Grade:____Age:___

Address: ___________________________________________________________________

Street/Apt Number City Zip code

Primary Phone Number: __________________________ Alternate Phone Number: _____________

As the parent (or legal guardian) of: _______________________________________ Child/Youth’s Name

I understand that my child/youth will be participating in a number of activities during the youth all-nighter.

Some of the activities are sports, games and other physical activities which the church may offer.

I consent for my child to participate in these activities.

Please indicate any restrictions on your child’s/youth/s activities:

______I represent that my child/youth is physically fit and has the necessary skills to safely participate in these activities.

______I represent that my child/youth has restrictions on the following particular activities:

______I also understand and give consent for my child to travel to and from these events in transportation provided by volunteer drivers.

MEDICAL TREATMENT AUTHORIZATION

It is my understanding that the Church will attempt to notify me in case of a medical emergency involving my child/youth. If the church cannot reach me, then I authorize the church to hire a doctor or health-care professional, and I give my permission to the doctor or other health-care professional, to provide the medical services he or she may deem necessary. I will pay for any medical expenses so incurred.

I will notify the church if I feel there are any health considerations that would prevent my child/youth’s participation in any of the activities listed above.

Allergies or other health considerations: _____________________________________________