General Authorization and Health Form
Please be sure you are completing this form under your child's name as the participant.
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Participant's FIRST name *
Participant's LAST name
 *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Current Grade *
Full Address (street address, town and zip) *
Home Phone *
Email Address *
Guardian 1 ( First & Last Name, Cell Phone, relationship) *
Guardian 2 (First & Last Name, Cell Phone, relationship)
TRANSPORTATION & EMERGENCY CONTACT:

I hereby give the above participant permission to participate and be transported to all planned activities and trips. In addition, I give permission to the Impact Youth Group Leaders to administer CPR/First Aid. In the event that Impact Youth is unable to reach me or the emergency contact person on this form, I hereby give permission to order whatever emergency treatment is deemed necessary.

Please sign below
 *
PHOTOGRAPHING & VIDEOTAPING POLICY

Throughout the course of events and regular youth group days, we will be taking pictures/video at camp for promotional purposes. These images/videos may appear in future program brochures, flyers, email-blasts and on our social media pages.

Please sign below providing consent for your child to be photographed/videotaped.
PERSON ITEMS AT EXTERNAL EVENTS:

Please refrain from bringing costly items/devices to large events. This signature acknowledges that you understand that the Impact Youth Group and Bridge Community Church is NOT responsible  for items brought that are lost, stolen or damaged.

Please sign agreeing to the above statement
 *
IN THE EVENT OF AN EMERGENCY:

Whom should we contact in the event of a medical emergency?
Additionally, please list (first & last name, cell phone, relationship to the child) at least one contact (not residing with you) that we can contact incase a parent or guardian can not be reached. 
 *
HEALTH ASSESSMENT
Please indicate if any of the following apply to your child.
 *
Required
If you checked off any of the above items, please give any details here. If there are any assertional conditions or medical issues you think we should be aware of in order to ensure your child's safety please indicate that here as well. 
Are there any foods your child cannot eat?
Please list any additional known allergies.
SPECIAL NEEDS (only fill out this section if your child has additional special needs you would like us to be aware of.)

If this section does not apply to you, please skip to the last question
Impact Youth and Bridge Community Church is committed to ensuring equal access to our events. In order to ensure we are providing a safe and appropriate environment for your child, please complete the following as applicable:
Classification/Diagnosis of Special Needs:

Please list which services your child receives, if any:
Behavior Support Needs: 

Does your child have behavioral issues that need to be addressed or that you would like us to be aware of?
I agree that all of the above information if complete, accurate and up to date as of the date this is signed. 
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