PARENTAL CONSENT FORM - Proclamation Presbyterian Church

Please complete both sides of this form
Activity:__________________________________ Date(s) of Activity:___________________
Name______________________________________________ Age_______ Birthdate________
Street Address _________________________________________ Phone (
City_________________________________ State_________ Zip _________
Parent(s) phone number for emergency contact (
) ___________________
The undersigned does hereby give permission for our (my) child, ________________________, to
attend and participate in the above-stated activity sponsored by Proclamation Presbyterian Church.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any 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, whether such diagnosis or
treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such
medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned
shall assume all transportation costs.
The undersigned does also hereby give permission for our (my) child to ride in any vehicle designated by the
adult in whose care the minor has been entrusted while attending and participating in activities sponsored by
Proclamation Presbyterian Church. Each child is required to wear a seat belt.
Parent or legal guardian
Phone #
Relationship to child
PLEASE LIST any allergies or special medication issues your child may have or any medication your
child needs to take during the event _______________________________________________________
Insurance Company
Policy Number
Release of all claims of youth participants and adult leader/participants who are not
official “Youth Group Leaders,” such as extra chaperones and drivers.
In consideration for being accepted by Proclamation Presbyterian Church for participation
in (event)____________________________________________
at (location)___________________________________________
on (date)________________________________________,
we (I), being 21 years of age or older, do for ourselves (myself) hereby release, forever discharge and
agree to hold harmless Proclamation Presbyterian Church and the directors thereof from any and all
liability, claims or demands for 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 child-participant
that occur while said child is participating in the above-described trip or activity.
Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 21 years]
hereby assume all risk of personal injury, sickness, death, damage and expense as a result of
participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said Church to furnish any necessary
transportation, food and lodging for this participant.
The undersigned further hereby agree(s) to hold harmless and indemnify said Church, its
directors, employees and agents, for any liability sustained by said Church as the result of the negligent,
willful or intentional acts of said participant, including expenses incurred attendant thereto.
If the participant has not attained the age of 21 years:
We (I) are the parent(s) or legal guardian(s) of this participant, hereby grant our (my) permission
for him/her to participate fully in said trip, and hereby give our (my) permission to take said participant
to a doctor or hospital, and hereby authorize medical treatment, including but not in limitation to
emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons,
disciplinary action or otherwise, we (I) hereby assume all transportation costs.
SIGNATURE: _________________________________________________________________
(Participant signs if 21 years of age or older. If participant is under 21, parent/guardian signs.)
This event is an activity of the ministry of Jesus Christ, our Lord and Savior. My attendance will enable
me to learn more about Him, enjoy the company of other youth, and enjoy the activities involved. In
keeping with this spirit, I promise to obey the instructions of the leaders, respect the rights of others,
refrain from sexual misconduct, and not to bring or use any non-prescribed drugs, narcotics, tobacco,
alcoholic beverages, pornographic materials, or weapons. I am aware that I may be sent home prior to
the expiration of this event if this pledge is violated.
Sign below if you accept the conditions above.
SIGNATURE OF PARTICIPANT: _____________________________________________________