Parental Consent/Medical Release Form—2013
I/We, as adult Representatives of McCarthy Baptist Church, understand that I/We will be responsible for the physical, emotional, and spiritual well being of the student or participant identified below while he/she participates in the youth event. I/We take this responsibility seriously, and will provide at minimum, the following:
All vehicles used to transport this student are insured, reliable, and have been maintained so as to present no immediate or predictable safety concerns. Tires have sufficient tread. Seat belts are available when legally required.
The driver of any vehicle transporting this student is Appropriately licensed, and appropriate credentials have been obtained. Also, all drivers driving McCarthy Baptist Church vehicles are covered by McCarthy Baptist Church’s insurance, which is adequate to cover medical bills should the child be injured because of driver negligence. Our insurance carrier is Guide One Mutual Insurance Co. and the policy number is #1178-390.
All adults and other leaders who have access to the student have been appropriately and reasonably screened by the police or other recognized agencies.
The medical and health needs of this student will be respected.
This agreement extends to not only McCarthy Baptist Church but also to all agencies, organizations, and people who act on its behalf to deliver any or all of the event.
By completing this form and signing below, you (the parent/guardian of said student) or ( a participant if not a minor) and I /(We) affirm that your student (named below) or you, (as a participant) is (are) authorized to participate in regular and special activities of the youth ministry of McCarthy Baptist Church and that I or any other sponsor as qualified above is authorized to act on behalf of McCarthy Baptist Church; and you (the parent/guardian) or (participant), agree and understand that your student or (yourself) will cooperate with the group and follow the rules according to the purpose and ultimate success of the event, and that I /We will provide reasonable supervision of all students throughout the event and that both/all parties involved will act in ways that reflect personal responsibility and Christian values, in the best interest of all parties involved.
Student or Participant Name: ________________________________________________________________
Age: _______________ Grade in School (if applicable): _______________ Birth Date: _______________
City: _____________________________________________________ State: ________ Zip: _________
Home Phone: __________________________________ Cell Phone: ______________________________
Medications Currently Taking: _______________________________________________________________
Behaviors or habits to beware of (sleepwalking, talking in sleep, hyperventilation, etc.):
Student//Parent’s or Participants Insurance Company: ________________________________________
Policy/Group Number: ______________________________________________________________________
Emergency Contact Number: ________________________________________________________________
Parent/Guardian Signature (if a minor) _____________________________________ Date _____________
Student/Participant Signature ____________________________________________ Date _____________
(MUST have both signatures if a minor)
(Stop - Bottom Portion to be filled out by Notary)
Name ___________________________________________________ My commission expires ____________
Date ________________ Signature____________________________________________________________
(stamp or seal below)