MEDICAL AND LIABILITY RELEASE FORM

Northwest Bible Church – Youth Ministries

889 W. Chapala Dr. Tucson, AZ.  85704 * 520-544-7775

Name of Student ______________________________________________________________________________________

Street Address ______________________________________________________ City/Zip __________________________

Home #  (______) ___________________ Parent/s work (_____) __________________ Cell #’s _______________________

Birth date ________________________    School _______________________________ Grade_____________________

Medical Insurance Company _________________________________ Group or Policy Number_________________________

In Emergency, notify ______________________________________________ Phone # _____________________________

Any Swimming Restrictions:       ______ Yes     ______ No           Any Activity Restrictions:          ______ Yes    ______ No

What restrictions? ____________________________________________________________________________________

Anything else we need to know about your son/daughter (allergies, epilepsy, heart condition, fainting spells, etc….) ___________________________________________________________________________________________________

Last Tetanus Shot __________________           E-Mail Address _________________________________________________

Liability Release

Every activity sponsored by this church is carefully planned and adequately supervised by mature adults.  However, even with the best of planning and precaution, unforeseen events can occur.  By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities.  They also agree not to hold this church or its employees or volunteer assistants liable for damages, losses or injuries to the person or property undersigned.  Either parent, if both parents have legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor had been entrusted to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medicine Practice Act or to consent to an X-ray examination, anesthetic, dental of surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act.  The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release.  This authorization shall remain effective until terminated in writing and delivered to an adult sponsor of Northwest Bible Church.

Parent/Guardian Signature ________________________________ Date _______________Circle one: Mother/Father/Legal Guardian

Student Behavior Contract

Our ministry seeks to create an environment of fellowship, activities, and programs that will, while working alongside families, train and educate students toward maturity in Christ.  A component of this environment includes certain behavior and cooperation standards that the students are expected to follow.  These standards include:

·          Following the direction of the staff leadership.

·          Showing respect and cooperation.

·          Respecting the rights and property of others.

·          Abstaining from the use of drugs, alcohol, and tobacco during any church sponsored activity.

·          Abstaining from any other activity deemed inappropriate for a church sponsored activity (i.e. public displays of affection and language).

When students choose not to abide by these standards, we will discuss with the student the need to cooperate.  Disciplinary responses may be given such as loss of free time and/or separation from the main group.  In more serious cases, the parent may be asked to pick up their son/daughter from the activity.  In all cases, the discipline will be administered in love and for the benefit of that individual student and for the entire group.

____________________________________________________________________________________________________________________

I have read the above statements of discipline policy and will abide by them.

______________________________________________                                             ___________________________

Student Signature                                                                                                           Date

I have read the above statements of discipline policy and am in agreement with them and will, if deemed necessary by the leadership, pick up my son/daughter from an activity.

______________________________________________                                              ___________________________

Parent/Guardian Signature                                                                                             Date