Youth for Christ

Authorization for Medical Treatment Form

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Participant’s Name:  _____________________________________Birth Date:  ______________

Parent/Guardian:______________________________________ Relationship:_______________

Address:__________________________City:_______________State:____Ph (____)__________

 

Authorization for Medical Treatment

 

This release and consent gives Youth for Christ permission to take my child to the nearest available medical facility and have any necessary emergency treatment administered.

 

I understand that every effort will be made to contact me.  However, in case of emergency, if I cannot be reached, I hereby give Youth for Christ permission to act on my behalf in seeking medical treatment by qualified personnel for my child in the event that such treatment is deemed necessary or advisable for my child’s health, safety and welfare.  I release Youth for Christ and all medical providers from liability in acting on my behalf in this regard in rendering such medical treatment.

 

In an emergency, you may call the person listed below in the event a parent cannot be reached:

Name:  ______________________________________________ Phone (____)______________

 

Current Medications: (Medications must be sent with participant in their original containers.)

Medication name                                   For                                                       Dosage

____________________                                                                                                                   

                                                                                                                                                           

                                                                                                                                                           

 

Health Insurance Co.:  ______________________________ Group No.:  __________________

Phone Number (____)________________                             

Insured under whose name?: __________________________                       

Participant’s Doctor:  ___________________________________Phone (_____)_____________

 

  Not Currently Insured – Youth for Christ reserves the right to subrogation if it is later determined that personal medical insurance was in place.

Youth for Christ is compliant with the Health Insurance Portability and Accountability Act (or HIPPA).

NOTE:  I understand that my personal insurance will be primary coverage for any accident and that Youth for Christ’s insurance is secondary up to a maximum of $25,000 ($750 for dental claims).  Youth for Christ’s policy does not cover illnesses.  If you have questions, please contact Youth for Christ Insurance Department at (303) 843-6790.

I have read and understand both sides of this agreement.

 

Signature Required:___________________________________Date:__________________

 

Youth for Christ

Release of Liability and Consent Form

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For: RIOT Overnighter    Date: April 16-17, 2010

Affiliated with: Venango Youth for Christ   Phone:  814-677-7013

Name of Person in Charge of Event: Ali Montgomery

 

Name of Participant:____________________________________  Birthdate:______________

Address of Participant: _________________________________________________________

                                                              (City)                           (State)                 (Zip Code)                                  (Phone)

 

Release of Liability

 

I understand that participating in Youth for Christ activities is a privilege.  In consideration of this privilege, I release Youth for Christ, including its directors, volunteers, employees and agents from any physical injury including death or illness while participating at a Youth for Christ activity, including Youth for Christ sponsored travel to and from this activity.

 

I understand that my child and/or I may participate in any number of activities, some of which include, but are not limited to, recreational activities and games.  I understand that there are certain risks associated with any activity, I will assume responsibility for these risks, whether known or unknown to me at this time.  This release is also intended to include all claims of my family, estate, heirs, personal representative or assigns.

 

If I am under 18, my parent or guardian, by signing below, also consents to my release and he or she agrees that this release shall be binding upon him or her as my parent or guardian as to me and my estate, heirs, personal representatives and assigns.  My parent or guardian also promises, by signing below to defend, indemnify and hold Youth for Christ harmless from any claim asserted by me against Youth for Christ, including its directors, volunteers, employees and agents, if I should repudiate this release after obtaining adulthood.

 

Consent

 

I hereby grant permission to Youth for Christ the right to use, reproduce, and/or distribute photographs, films, video-tapes, and sound recordings of my child, without compensation or approval rights, for use in materials created for purposes of promoting the activities of Youth for Christ.

 

I have read and understand both sides of this agreement.

 

Signature Required:_______________________________________Date:__________________

Relationship to Participant (Circle one):  Parent  Guardian 

 

Signature of minor participant: ________________________________Date:________________

   (If participant is emancipated, proof must be provided prior to activity)