Youth Activity Authorization and Medical/Liability Release

Please fill out the form below, then hit the “submit” button.
This release will expire on December 31st of each year, so you will need to fill out a new one for each year of your student’s participation.

  • MEDICAL HISTORY

  • (Group leaders must be informed of any prescription medication brought by youth, with clear information as to proper use and dosage. If medication is as needed, your child must understand the symptoms of their condition and know when to ask for help.)
  • Physician and Insurance Information

  • (The number needed to verify coverage or submit a claim)
  • Medical and Parental Consent and Release

  • MEDICAL CONSENT: As the legal guardian, if the participant is a minor under the age of 18, I hereby attest that I have read this complete document; all information provided is complete and true; I have legal standing to make decisions which affect the rights of the above-named participant; and, I understand and consent to all terms outlined in this document. I hereby voluntarily and knowingly assume all risks and dangers inherent and incidental to Youth Ministry activities and travel, understanding that some activities may pose a risk of injury. I will not hold liable Countryside Community Church, its employees, agents and event/youth group leaders for any injury, illness or property damage involving the above-named participant, no matter how caused. Whenever deemed necessary by group leaders, I authorize the calling of a doctor and/or the providing of other medical services and, unless covered by insurance, agree to pay for same. If the above-named participant is incapacitated or under age 18, I do hereby authorize group leaders as agent for the undersigned, to consent with respect to such participant to any x-ray examination, anesthetic, medical, dental or surgical diagnosis and/or treatment, and hospital care which is deemed advisable by a state-licensed physician or surgeon.

    PARENTAL CONSENT (for minor under age 18): As legal guardian of the above-named minor under the age of 18, I give my permission for him/her to be involved in the Youth Ministry program(s) of the Countryside Community Church, Sherwood, Oregon. I am familiar with the general goals and purpose of the program(s). I understand I will be notified of any special activities and trips away from church, including location, form of travel and cost. Should my child choose to attend such activities, I agree to send them with the appropriate clothes, personal items and money needed. Unless I have made special arrangements with a group leader, transportation to/from church or group activities, or to a common drop point for group travel, is the child and parent's responsibility. If my child needs to be sent home for any reason, including behavior problems or medical reasons, I agree it will be at my expense.

    PHOTOGRAPHY RELEASE: I hereby grant the Church and its representatives permission to use, without compensation or restriction, photographs and videotape images in which the participant appears, in any manner whatsoever such as, but not limited to: publication, display, advertising, slide shows, etc.

    CONFIDENTIALITY: I understand that health information of this form will only be shared, as needed, with group leaders, Church staff and medical professionals to safeguard and support the participant. This information will not be publicly disseminated or released to outside organizations. However, since it is common practice for the Church to publish a participant's address, phone number and/or birthday on the group's roster, if they actively participate in the group, I authorize the Church to publish such information on a local (or event) roster.

    LIMIT OF CONSENT: The consent outlined in this Youth Activity Authorization/Medical/Liability Release, concerning my child's participation in Youth Ministry activities, expires on December 31st. It is my responsibility to notify the group leaders or minister if any information changes or I decide to withhold consent.

  • (This will serve as your digital signature)