RLBC Youth Social Media Consent Form 2024

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Consent and Liability Release for Participation in Robert Lee Baptist Church youth ministry activities, programs, events, and gatherings.
This form MUST be filled out by a parent or guardian.

Email *

Student's Name *

Student's Birthday *

YYYY

Student's Grade *

Parent/Guardian's Name *

Relationship to student *

Parent/Guardian Phone Number *

Address *

Emergency Contact Name *

Emergency Contact Number *

Please list any medical/physical limitations, including food allergies, or other concerns pertaining to your student: *

Family Doctor's Name *

Doctor's Phone Number *

Insurance Company *

Insurance Policy Number *

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of Robert Lee Baptist Church and any other supervised activities customarily associated with its youth group, including youth hangouts, rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing. By electronically signing below, I hereby indemnify and hold harmless Robert Lee Baptist Church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising as a result of injury or illness of my child during youth ministry involvement. *

I, the undersigned, being the parent or legal guardian of the youth named above, understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth, if required by law or a health care provider: Danielle Hurd, Susan Pentecost or Christopher Walls. I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care. I understand that Danielle Hurd, Susan Pentecost, Christopher Walls, and Robert Lee Baptist Church will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the youth director in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the youth leader and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth. Typing your name below *

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