Parental/Guardian Consent and Release Form

Student Name:


Date of Birth:

Student Grade:

Parent(s) Name:




ZIP Code:

Home Phone:

Parent’s Mobile #(s):

Student’s Mobile #: (youth leader(s) may call or text your student at this number)

Additional Contact/Emergency Name(s) & Numbers:

Parent’s Email:

Student’s Email:

Health Insurance Company:

Policy/Group #:

ID #:

List Allergies and/or Other Physical or Mental Health Considerations (if none, enter NONE):

I, am the parent or legal guardian of who was born on . I warrant that I possess all the rights, powers and privileges of a parent or legal guardian necessary to execute this document with binding legal effect.
As the parent or legal guardian I certify and affirm that I have been completely and thoroughly informed that as a youth attending Bethlehem Covenant Church, my child will participate in certain activities which carry with them a degree of risk and danger. Examples of risky and dangerous activities include, but are not limited to: 1) physical activities, both indoors and outdoors; 2) sports, both informal and organized; 3) use of recreational equipment; 4) field trips, both on and off church campus; 5) travel by automobile; 6) camping; 7) hiking; 8) activities around water, including swimming and boating. I acknowledge and understand that Bethlehem Covenant Church may offer other activities not listed above that present similar risks or dangers to my child. I also understand and give consent for my child to travel to and from these events in transportation provided by volunteer drivers, from July 1st, 2016 to October 1st, 2017.
In consideration of my child being allowed to participate in these activities and to use Bethlehem Covenant Church’s equipment and facilities, on behalf of my child, I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless Bethlehem Covenant Church from any and all claims, demands, or causes of action, which are in any way connected with my child’s participation in these activities or use of Bethlehem Covenant Church’s equipment and facilities.
In cases of emergency, I further consent to the examination of treatment of my child by a physician duly licensed to practice medicine or any health care professional duly licensed to provide health care services for medical care and services deemed necessary by Bethlehem Covenant Church, its agents, servants, and employees. I give permission to the doctor or health care professional to provide any and all medical care they deem, in their professional opinion, to be necessary. I agree to pay for any and all medical expenses incurred as a result of the use of this consent. I understand that it is my obligation to inform the management of Bethlehem Covenant Church of any and all health considerations or medical conditions that would restrict my child’s participation in any and all activities while at Bethlehem Covenant Church, should the need for medical attention arise.
By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in these activities, I may be found by a court of law to have waived my right to maintain a lawsuit against Bethlehem Covenant Church on the basis of any claim from which I have released them herein. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. I have fully informed myself of the contents of the PARENTAL AUTHORIZATION, CONSENT AND RELEASE by reading it before I signed it. I will notify Bethlehem Covenant Church if I feel there are any health considerations that would prevent my child’s participation in any of the activities listed above.

I give permission for photos and/or videos of my child to be used in Bethlehem Covenant Church publications, and promotional materials, including both print and video on our websites online:

Child’s Name:

Date Signed:

Leave this empty:

Bethlehem Covenant Church
Signature Certificate
Document name: Parental/Guardian Consent and Release Form
Unique Document ID: 5c00b1ce38d54c1a73395990cd8af4124e6641e4
Timestamp Audit
2016-01-22 13:55:54 CDTParental/Guardian Consent and Release Form Uploaded by Starla TeKrony - IP