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Youth's Full Name (First Middle Last)*
Go-By Name
Birthdate* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Youth's Cell Phone( ) -
Name*
Email*
Primary Phone*( ) -
Primary Phone Type* Cell Phone Home Phone
Work Phone( ) -
Other Phone( ) -
Different address than youth? Yes No
*Someone who doesn't live with the youth
Contact Name*
Relationship to your youth*
Contact Primary Phone*( ) -
Contact Work Phone( ) -
Contact Other Phone( ) -
Is there anyone NOT authorized to pickup your youth?
Have Frequent Headaches?
Ever had a head injury?
Ever been knocked unconscious?
Wear glasses or contacts?
Ever had seizures?
Ever had high blood pressure?
Have diabetes?
Have asthma?
Have problems sleeping or sleepwalking?
Ever had an eating disorder?
Other chronic or recurring illness?
N/A
Please Explain Above Answers
Medication Allegries (Reaction and Treatment)
Food Allergies (Reaction and Treatment)
Please Explain Any Other Dietary Restriction
Other Allergies (Reaction and Treatment)
Please explain any additional health information we need to know.
Date of Last Tetanus Shot January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Date of Last Tetanus*
Youth's Swim Ability* Non-Swimmer Weak Swimmer Swimmer
Does your youth take any medications regularly, prescription or non-prescription?* Yes No
If Yes, please provide the information below.
Medications Taken
Name of Drug, Dosage, and Frequency
Primary Physician*
Primary Physician's Phone*( ) -
Primary Dentist/Orthodontist
Primary Dentist/Orthodontist Phone( ) -
Insurance Company
Policy Number
Name of the Primary Insured
I, the Parent or Guardian (“Parent”) and my minor child (“Participant”), desire for my minor child to participate in the Crestwood Baptist Church youth group (“Youth Group”) events in 2016. I have read and understand the Risk Acknowledgement and Assumption of Risk.below. |--------- Risk Acknowledgement--------| I acknowledge and understand there may be dangers, hazards, and risks inherent in, associated with, or arising out of Crestwood Baptist Church youth group (“Youth Group”) events, or acts by third parties unrelated to the Youth Group. I recognize that these risks could result in injury, illness, emotional injury, property loss, serious injury, or death. |--------- Assumption of Risk----------| In consideration for participation in Youth Group events, I do hereby release and hold harmless Crestwood Baptist Church and their leaders, employees, and volunteers, from any and all claims, liabilities, suits, actions, causes, damages, or losses. I do hereby indemnify and hold harmless Crestwood Baptist Church from any and all claims, demands, actions, fees, and costs for any loss, injury, damage or expense whatsoever that might arise out of my or my child’s participation in the Youth Group events. These terms hereby shall serve as a release and assumption of risk for me, my heirs, executors, administrators, and for all members of my family.
I have read and understand the following: |---------Medical Release----------| In the event of an accident or illness, I authorize the Youth Group personnel to administer first aid by examining, treating, or administering medications for said illness or injury to my Participant as deemed necessary. In the case of an emergency, I authorize the Youth Group to obtain medical treatment (including hospitalization, injection, anesthesia, and surgery) from a licensed, certified or authorized health care provider for my Participant. I authorize the Youth Group to transport or arrange for transportation for my Participant to receive said medical treatment. I hereby hold harmless and agree to indemnify Crestwood Baptist Church, its officers, directors, trustees, agents, employees, and volunteers from and against any claims, damages and/or liabilities, arising out of or resulting from said care rendered or professional medical treatment received or transportation to said care. |----------Transportation Release----------| I authorize the Youth Group to transport my Participant to, from, and for Youth Group events. This may include vehicles owned by Crestwood Baptist Church, rented vehicles, or privately owned vehicles. I hereby hold harmless and agree to indemnify Crestwood Baptist Church, its officers, directors, trustees, agents, employees, and volunteers from and against any claims, damages and/or liabilities, arising out of or resulting from said transportation. |----------Media Release----------| I understand that pictures and videos are taken at Youth Group events. I hereby give permission for the use of such pictures and videos of the Participant for the promotion of the Youth Group.
Signature*
Sign in the space above by writing your name. By signing you acknowledge and represent that you have read and understand the Risk Acknowledgement and Release above. Also, you accept the Assumption of Risk, Medical Release, Transportation Release, and Media Release.