Youth Information and Permission Form

Student's Name

First Name

Last Name

Name Student Goes By

Date of Birth

YYYY

Gender

T-Shirt Size

School

Grade

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Student's Phone

(###)

###

####

Student's Email

Guardian 1 Name

First Name

Last Name

Guardian 1 Phone

(###)

###

####

Guardian 1 Email

Guardian 2 Name

First Name

Last Name

Guardian 2 Phone

(###)

###

####

Guardian 2 Email

Emergency Contact

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Emergency Contact Relationship to Child

Allergies

Does Your Child Have An EPI Pen?

Special Diet Considerations

Should Your Child's Activities Be Restricted For Any Reason?

If Yes, Please Explain

Family Physician

Physician Phone

Family Insurance Company

Insurance Policy Number

Medications

Known Medical Conditions

Medical Authorization and Release (Please read and initial)

This consent form gives permission to seek whatever medical attention is deemed necessary, and releases Zebulon Baptist Church and its staff of any liability against personal losses of named child. I/We the undersigned have legal custody of the student named below, a minor, and have given our consent for him/her to attend events being organized by Zebulon Baptist Church (“Church”). I/We understand that there are inherent risks involved in any ministry or athletic event, and I/we hereby release the Church, its ministers, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my/our child’s involvement While I understand that the Church will take all reasonable steps to provide individual care and safety for my child, I am aware that the Church or their employees or agents cannot assume any responsibility for an injury, damage or harm which might result during the course of any activity during functions so sponsored. In consideration of permitting my child to participate, I agree that full responsibility will remain with me, as parent or guardian of my child. Should any claim be asserted by any person as the result of the acts of my child while participating in the course of activities provided by the Church, or traveling to or from such activity, or should my child assert any claim against the Church or its employees or agents, I agree to indemnify and hold the Church harmless from any such claim, including attorney fees and costs incurred by the Church in defense thereof. In the event that he/she is injured and requires the attention of a doctor, I/we consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is required from a physician and/or hospital personnel designated by the Church, I/we agree to hold such person free and harmless of any claims, demands, or suits for damages arising from the giving of such consent. I/We also acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider. Further, I/we affirm that the health insurance information provided above is accurate at this date and will, to the best of my/our knowledge, still be in force for the student named below. I/we also agree to bring my/our child home at my/our own expense should they become ill or if deemed necessary by the Church staff member. This document also gives my/our permission for my child to travel and attend all activities sponsored by Zebulon Baptist Church from August 1, 2024-July 31, 2025.

Photo & Video Release

I certify that I am 18 years of age or older and hereby give ZBC permission to use photos and images of me and/or my child in church publications and/or the church website with the understanding that, in either case, the children will not be identified by name. If you select “no”, ZBC will NOT use photographs of you or your child.

Form Signature (Please Read And Sign Below)

The undersigned may execute this instrument electronically (by fascimile, pdf or any “Electronic Record” (as such term is defined in the Electronic Signatures in Global and National Commerce Act at 15 U.S.C. §7001 et seq. (“ESIGN Act”)). Such an electronic signature will constitute an original and binding signature of the undersigned. Any writing (whether on paper or in electronic format) prepared by the undersigned and delivered to Zebulon Baptist Church) may be legally relied upon by Zebulon Baptist Church without regard to the medium in which the record is maintained or the method of delivery or transmission.

Date

YYYY