"Summer Outreach That Works" -- sample permission slip
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Sample Parent Medical and Liability Release Statement: |
I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary. I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by (name of the church or organization) through its accident policy will be used as a backup for what my family's insurance does not cover. I understand all reasonable safety precautions will be taken at all times by the (name of the church or organization) and its agents during the events and activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold (name of church or organization), its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. Parent/Guardian Signature: ________________________________________ Date: ___________ Signature of Student (if over 18 years of age): __________________________________________
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| Sample Parent Information and Release Form |
| (Name of Church of Youth Ministry) Parent/Guardian Information and Permission Form Name of Activity and Dates (Please Print) Name of Student: _________________________________ Date of Birth: _______________ Age: _______________ Address: _____________________________________________________________ Town: _____________________________ State: ___________ Zip: _____________ Phone Number: ____________________________ Sex: ___________ |
| Sample Student Information and Code of Behavior Agreement |
Description of the activity/event and dates (for example): What you will be doing? ______________________________________________________________ Departure and return times/locations: ____________________________________________________ Supervision and free time activities: _____________________________________________________ Accommodations and curfew times: _______________________________________________________ How you can be reached by phone: ________________________________________________________ Listed below are some of the activities we have planned to offer to the students during the trip. Place your initials next to specific activities listed below to indicate your approval of your child's participation. (for example): ______ horseback riding ______ playing in sports ______ rock climbing ______ swimming in a lake ______ canoeing ______ walking the ropes course ______ participating in the program ______ other |
| Rules of Behavior Expected of Each Student (for example) |
1. No alcohol or drugs permitted. 2. Attendance at meetings is mandatory. 3. No guys in girls sleeping quarters (vice versa, too) 4. Follow curfew. 5. No smoking. 6. Other ____________________________ |
| Parent and Student Release Statement: |
As parent/legal guardian of (name of student), I have reviewed the information about the youth ministry activity/event and give my permission for the subject of this release to be involved in the overall activities and in the specific activities that I have initialed above. I/We have reviewed the rules of the activity and agree that the subject of this release will abide by them. I/We also acknowledge that if the subject of the release has to return home early for discipline violations, it will be at my/our expense. I/We consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed, or shown as (name of the church or organization) sees fit. I/We understand all reasonable safety precautions will be taken at all times by the (name of the church or organization) and its agents during the events and activities. I/We understand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold (name of church or organization), its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. Parent/Guardian Signature ______________________ Student Signature _____________________________ Date ______________________________________ |
