Youth Activities Consent Form




Name of youth________________________________ Birth date_________________________

Name of parent(s) or guardian(s)__________________________________________________ Address_____________________________________________________________________Home telephone______________________ Work telephone____________________________

Other person and/or number to call in emergency_____________________________________


Medical Information

Is your youth presently being treated for an injury or sickness or disease or taking any medication?

Yes_________ No __________ If yes, please explain.



Family Doctor_________________________  Doctor’sTelephone (_______)_________________

Insurance Co. ____________________________________ Policy No.____________________


Consent and Certification

I, the undersigned, being the parent or legal guardian of the youth named above, do hereby consent to the participation of my youth in all the scheduled youth activities of Swan Lake Church, and any other supervised activities customarily associated with its youth group, including youth rallies and overnight or weekend youth trips. Further, I certify that my youth is physically fit and adequately prepared to participate in all recreational and sporting events. If I wish to revoke this consent for any reason, I will promptly notify the youth leader in writing.


Medical Treatment Authorization

I understand that I will be notified in the case of a medical emergency. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event that my youth is injured or becomes ill. I authorize one or more of the following persons to make emergency medical care decisions on behalf of my youth, if required by law or a health care provider: __________, ___________, or another adult chaperone designated by the Youth pastor.


I authorize these persons to act in my place to consent to all necessary and appropriate x-ray examinations, anesthetic, medical or surgical diagnosis or treatment, and hospital care.

I understand that they will not be responsible for medical expenses incurred solely on the basis of this authorization. I further agree to notify the youth director in writing of any health changes that would restrict my youth’s participation in any normal youth activities. I also understand that the youth leader and designated adult chaperones reserve the right to restrict my youth from any activity that they do not feel is within the physical capabilities of my youth.


__________________________________ Signature of Parent or Guardian   Date____________


Youth Pledge

I hereby pledge to uphold all policies of the Youth Department of Swan Lake Church. During all youth activities and all youth trips, I pledge to follow all instructions of the youth leader and the adult chaperones, including safety instructions.

___________________________________ Signature of Youth    Date______________________