Youth Ministry Permission Form

This form is to be completed by the youth's parent/guardian. Youth should not complete this form on behalf of their parent/guardian. You do NOT need to fill it out again if you have already submitted it for a previous Youth Ministry event.

Your name *

Email address *

Participant Information

Participant 1: Name *

Participant 1: Birthdate *

Participant 1: Grade *

Participant 1: School Name *

Participant 1: Member of SMBC *

Participant 1: Please enter medications the participant is currently taking (if any):

Participant 1: Please enter the participant allergies (if any):

Participant 1: Please enter any medical conditions we should be aware of (if any):

Parent/Guardian Information (For participants under 18)

Full Name of Parent/Guardian *

Relationship to Participant(s): *

Contact Number (Primary): *

Contact Number (Secondary):

Email Address: *

Emergency Contact Information

Emergency Contact Name: *

Emergency Contact Relationship to Participant(s): *

Emergency Contact Phone Number: *

Alternate Emergency Contact Name:

Alternate Emergency Contact Phone Number:

Consent and Agreements

Parental/Guardian Consent: I hereby give permission for my child to participate in Youth Ministry activities, programs and events. *

Liability Waiver: I agree to release Shiloh Missionary Baptist Church from any liability related to Youth Ministry activities, programs and events. *

Photo/Video Release: I give permission for photos/videos of my child to be used for promotional purposes. *

Emergency Medical Consent: In the event of an emergency, I authorize the event organizers to seek medical treatment for my child. *

I acknowledge by checking this box and typing my name it is the same as signing this document. *

Parent Name: *

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