Universal Permission Form 2021-2022

Effective Dates: July 30, 2021 - August 31, 2022

Student Information

Please fill out ONE form per student. This allows each student to fill out and submit each signature form and helps us as leaders to find needed information per student quickly, especially in the event of an emergency.

Student Name

Preferred Nickname:

School

Grade

Gender

Male Female

Birthdate

Student Email

Student Phone

Primary Address

Secondary Address

Parent/Guardian Information

Name 1

Name 2

This address will receive a confirmation email

Primary Phone

Please list ALL phone numbers where parents/guardians can be reached.

Cell Phone 1

Cell Phone 2

Work Phone 1

Work Phone 2

Home Phone 1

Home Phone 2

Other Emergency Contacts

Please list at least TWO other emergency contacts besides parents/guardians.

Name:

Phone

Relationship to Student

Name:

Phone

Relationship to Student

Medical Information

Primary Care Physician:

Primary Care Physician Phone

Date of Last Tetanus

List all allergies (medicine, food, environmental) and the severity and type of reaction.

Special Medical Instructions:

Medication: List all medications your student will take during any youth ministry trips, retreats, or events. This includes any prescription or non-prescription medications, herbal supplements, and vitamins.

Please list medication name, dose, treatment for, and dispensing instructions for ALL medications. If no meds are taken, please say

Do you give permission for your student to be given over-the-counter medication as needed and as directed on the label to treat non-emergent medical conditions that do not require a doctor or hospital visit such as a minor headache, stomach ache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry event?

No. Contact me or get medical help if my child has any minor medical concerns. Yes. I give permission for an adult leader to give my child over-the-counter medications on a need basis to treat non-emergent medical concerns.

Insurance Information

Insurance Company:

Insurance Phone:

Policy/Group ID #:

Policy Holder's Name

Upload an image of the front of your insurance card:

Upload (8MB)

Upload an image of the back of your insurance card:

Upload (8MB)

Parental Consent

By clicking below, I give permission for my child

(“Participant”) to attend and participate in any Bethesda children / youth ministry activities, events, and retreats during the period of September 1, 2020 – August 31, 2021.

LIABILITY RELEASE: In consideration of Bethesda allowing the Participant to participate in children / youth ministry, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Bethesda, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children / youth activities. I, the parent or legal guardian of this Participant, hereby grant my permission for the Participant to participate fully in children / youth ministry activities, including trips away from the church premises. Furthermore, I, on behalf of my participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by the church as the result of negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to administer first aid and/or consent to an emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costa and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY HOME RETURN POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child / youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Bethesda Baptist Church. My child / youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.

MEDIA: I hereby give Bethesda permission to reproduce, edit, exhibit, project, display, copyright, and publish, photographic images and/or moving pictures and/or videotaped images of me and/or Participant, with or without voice, in which I and/or Participant are included, in whole or in part, photographed, taped, videotaped, and/or recorded prior to, during, and/or after activities and events.

Student & Parent Covenant

REQUIRED: Please print this PDF file and review with your student. BOTH student and parent need to sign, date, and then return this covenant to the Student Ministry Director.

Covenant of Community Expectations

Description

Please fill out this form and click submit. Print the linked covenant form at the bottom, read and review with your student, sign with your student, and submit to Brigitte Creech.

Universal Permission Form 2021-2022

Description

Please Fix the Following