Children and Youth Permission Form

Child/Youth (name):

This child/youth has my permission to participate in the following

Event name (if applicable)

Location:

Date(s) of event:

I give permission for transportation, if needed, to be provided to and from this event by drivers designated by the leader in charge of the event (sign or initial below):

Medical and emergency information

Primary Physicians name and phone number:

If you have registered this year with CYF Ministries, we have your emergency contact information. Otherwise, please provide your name and number, and the name and number of an emergency contact:

I give permission to the adults in charge to take emergency action in the event my child/youth sustains an injury or becomes ill while attending this event (sign or initial below):

I give my consent to emergency medical treatment, to include an x-ray examination, anesthetic, medical, dental, or surgical diagnosis, treatment and hospital care, and the administration of drugs or medicine that is deemed necessary for my child/youth under general or specific supervision and upon the advice of a duly licensed physician and/or surgeon. I also agree to assume liability for any resulting expense that is not covered by my child/youth’s medical insurance (sign or initial below):

My child/youth does NOT take any medications on a daily/regular basis (sign or initial below):

My child/youth DOES take medications on a regular basis, listed below:

My child/youth has the following known allergies (please include allergies to medicines and what medications are taken for all allergies):

My child/youth has the following known health concerns (asthma, seizures, etc.):

My child/youth has the following support and/or access needs (examples: communication, social, physical, etc.):

Insurance information (only needed once per calendar year)

Insurance Provider:

Policy #:

Subscriber's name:

Subscriber's Employer:

WHEN COMPLETED, PLEASE SIGN & DATE BELOW

Parent/Guardian Signature:

Date:

Description

Please fill out this form and click submit.

Children and Youth Permission Form

Description

Please Fix the Following