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Life Fellowship Church

2017 YOUTH ACTIVITY RELEASE FORM

PARENT INFORMATION & MEDICAL RELEASE

I the undersigned, parent or legal guardian of the minor listed below do authorize any X-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any state licensed physician consent of Austin Clark, Life Fellowship Church Youth Pastor, and/or authorized Life Fellowship Church sponsors/leaders, the temporary custodian of the minor. I further acknowledge that any activity carries a risk of incident or accident resulting in injury or possible fatality and do hereby release liability of Life Fellowship Church, Pryor, Oklahoma, its staff, and/or sponsors/leaders in case of such an occurrence. This consent shall remain effective until 12:00 midnight on the 31st day of December2017, unless sooner revoked in writing and delivered to Austin Clark of Life Fellowship Church, Pryor, Oklahoma. A signature of parent/legal guardian is required on this form. I acknowledge that it is assumed by Life Fellowship Church that a parents and/or legal guardian of the stated minor have signed this form and acknowledge sole responsibility for release.

I also acknowledge and give consent for the minor listed below, of whom I hold legal custody, to participate in Life Fellowship Church activities in which the following conditions may exist (Consent is acknowledged by parent or legal guardian initialing next to each condition):

  • I acknowledge that my/our child may be riding in an automobile driven by only one approved adult leader and no fewer than two minors; never is there to be one adult and one minor left one on one in a vehicle. (initial) ____ DATE ___/___/2017
  • I acknowledge and approve of my/our child participating in over-night church activities. (initial) ____ DATE____/___/2017

As the parent or legal guardian of the stated minor, I acknowledge that I have read and understand the policies and procedures on this form of Life Fellowship Church, Pryor, Oklahoma. (initial) ____ DATE____/___/2017

Minor’s Name: ______

Date of Birth: ____/____/____

Parent/Legal Guardian: ______/____/____

(Print) (Signature) (Date)

Phone #: ______Emergency #: ______

Address: ______City: ______State: ___ Zip: ______

Health Insurance Plan: ______Policy #: ______

(Please list any allergies or other complicates on pg. 2 of form)

DATE: ____/____/_2017

Allergies: ______

Medications:

______

Other:

______