Parental Consent/Medical Treatment Form
General Release and Hold Harmless for SYRACUSE TOUR 2010
The undersigned or a member of the immediate family of the undersigned desires to participate in
various programs, events, or activities (hereinafter collectively referred to as “Activities”) operated or
sponsored by the North Central Assembly of God (hereinafter referred to as “Church”) and Revolution Student
Ministries (hereinafter referred to as “Youth Ministry”).
The undersigned or a member of the immediate family of the undersigned further understands and
acknowledges that the undersigned or a member of the immediate family of the undersigned may incur
personal injury or bodily damage while participating in such Activities.
The undersigned or a member of the immediate family of the undersigned further understands and
acknowledges that the Church and Youth Ministry would not allow the undersigned or a member of the
immediate family of the undersigned to participate in such Activities without releasing and holding
harmless the Church and Youth Ministry.
Further, the undersigned or a member of the immediate family of the undersigned request that the
Church and Youth Ministry in consideration thereof agree to release, and forever discharge the Church
and Youth Ministry, their officers and directors, and their employees, and their agents, and any parties
volunteering on behalf of the Church and Youth Ministry from all actions, claims, costs, expenses or
damages of any kind growing out of or related to any Activity of the Church and Youth Ministry in which
the undersigned or a member of the immediate family of the undersigned participates.
The undersigned or a member of the immediate family of the undersigned further acknowledges that
this is a full and complete release for all injuries and damages which the undersigned or a member of
the immediate family of the undersigned may sustain as a result of the undersigned or a member of the
immediate family of the undersigned participating in any Church program.
I, __________________________________________________________, being the legal guardian of
_________________________________________________ give my permission for him/her to attend
and participate in all the activities of _____________________________________________________
under the direction of the Youth Ministry.
The undersigned, being a parent and/or legal guardian of the above minor, does hereby authorize the
treatment of the above minor by a qualified and licensed medical doctor in the event of a medical
emergency which, in the opinion of the attending physician, may endanger his/her life, cause
disfigurement, physical impairment, or undue discomfort if delayed, while said minor is participating in
the above event, including transportation to and from the event site. This authority is granted only after
a reasonable attempt has been made to contact me.
Medical Information
Please list any allergies, medications, medical information, or chronic illnesses your student may have
on the back of this form.
Signed: ________________________________________________ Dated: ______________
(participant’s parent or legal guardian)
Home Phone #: ______________________ Emergency Phone #: ______________________
Parental Consent/Medical Treatment Form
General Release and Hold Harmless for SYRACUSE TOUR 2010
The undersigned or a member of the immediate family of the undersigned desires to participate in
various programs, events, or activities (hereinafter collectively referred to as “Activities”) operated or
sponsored by the North Central Assembly of God (hereinafter referred to as “Church”) and Revolution Student
Ministries (hereinafter referred to as “Youth Ministry”).
The undersigned or a member of the immediate family of the undersigned further understands and
acknowledges that the undersigned or a member of the immediate family of the undersigned may incur
personal injury or bodily damage while participating in such Activities.
The undersigned or a member of the immediate family of the undersigned further understands and
acknowledges that the Church and Youth Ministry would not allow the undersigned or a member of the
immediate family of the undersigned to participate in such Activities without releasing and holding
harmless the Church and Youth Ministry.
Further, the undersigned or a member of the immediate family of the undersigned request that the
Church and Youth Ministry in consideration thereof agree to release, and forever discharge the Church
and Youth Ministry, their officers and directors, and their employees, and their agents, and any parties
volunteering on behalf of the Church and Youth Ministry from all actions, claims, costs, expenses or
damages of any kind growing out of or related to any Activity of the Church and Youth Ministry in which
the undersigned or a member of the immediate family of the undersigned participates.
The undersigned or a member of the immediate family of the undersigned further acknowledges that
this is a full and complete release for all injuries and damages which the undersigned or a member of
the immediate family of the undersigned may sustain as a result of the undersigned or a member of the
immediate family of the undersigned participating in any Church program.
I, __________________________________________________________, being the legal guardian of
_________________________________________________ give my permission for him/her to attend
and participate in all the activities of _____________________________________________________
under the direction of the Youth Ministry.
The undersigned, being a parent and/or legal guardian of the above minor, does hereby authorize the
treatment of the above minor by a qualified and licensed medical doctor in the event of a medical
emergency which, in the opinion of the attending physician, may endanger his/her life, cause
disfigurement, physical impairment, or undue discomfort if delayed, while said minor is participating in
the above event, including transportation to and from the event site. This authority is granted only after
a reasonable attempt has been made to contact me.
Medical Information
Please list any allergies, medications, medical information, or chronic illnesses your student may have
on the back of this form.
Signed: ________________________________________________ Dated: ______________
(participant’s parent or legal guardian)
Home Phone #: ______________________ Emergency Phone #: ______________________