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Youth Ministry Emergency Medical Authorization | Liability Release | Photo Release

An emergency medical and photo consent is required for a church youth group to ensure that leaders can seek prompt medical treatment for a child in case of an emergency when a parent or guardian is not immediately available, and to obtain permission to use photos of the child for church-related materials, such as newsletters or social media, while respecting privacy and legal requirements.

Your name *

Last name

Email address *

Student's Name *

Birthdate *

Grade

School

Gender *

Address *

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone Number *

T-Shirt Size *

Medical Permission | Parental Consent

In case of emergency or injury while participating with the North Clinton Senior High Youth Ministry, we need your parent's/guardian's consent to administer medical treatment or secure hospitalization. This Authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery are obtained prior to the performance of such surgery.

Emergency Contacts

Father's Name

Mother's Name

Medical Insurance Company *

Basic Medical Information

I am allergic to:

(ex: Latex, milk products, egg products, foods, bee stings, wasp stings, etc)

I am allergic to the following medications:

(ex: Penicillin, aspirin, sulfa etc)

I am subject to:

(Check if applicable)

Frequent Fainting

Sleep Walking

Heart Condition

High Blood Pressure

Diabetes Mellitus Type 1

Diabetes Mellitus Type 2

Other

Last Tetanus Vaccine?

I take the following prescribed medications & dosages

Other Medical Conditions

(Please Explain)

Photo Release

Photo Release *

I hereby grant North Clinton Church permission to use my likeness and my child's likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of North Clinton Church and will not be returned. I hereby irrevocably authorize North Clinton Church to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. I hereby hold harmless, release, and forever discharge North Clinton Church from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization. I have read and understand the above photo release. I affirm that I am at least 18 years of age and am signing this for myself and/or my children or legal dependents.

Yes

Other

Waiver

By signing this document, I grant my child permission to participate in group outings. I completely understand that I will not hold North Clinton Church, Wauseon, or the people involved, including drivers with this outing liable/responsible for any injuries or accidents that occur. I hereby grant permission to receive proper medical treatment or hospitalization in case of an emergency or illness.

Parent/Guardian Signature___________________________________ Date __________ *

Student Signature _________________________________________ Date __________ *

A copy of your responses will be sent to your email address.

North Clinton Church
info@northclinton.org
419-337-4776