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Youth Medical & Liability Form
Contents
Youth Medical & Liability Form
Youth Medical & Liability Form
Name of Participating Youth
Address
Name of Parent/Guardian
Emergency Contact
Youth Medical & Liability Form
Youth Medical & Liability Form
Today's Date
Name of Participating Youth
First Name
Middle Initial
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo (Congo-Brazzaville)
Costa Rica
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (fmr. "Swaziland")
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine State
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Birth Date
Name of Event
Date of Event
Name of Parent/Guardian
First Name
Last Name
Parent/Guardian Phone
Parent/Guardian Email
Emergency Contact
First Name
Last Name
Relationship to Youth
Mother
Father
Sister
Brother
Grandmother
Grandfather
Aunt
Uncle
Friend
Other
Emergency Contact Phone
Acceptance
I, the undersigned parent or legal guardian of the child named above, do hereby grant my permission and consent for the said child to attend and participate in the events and activities of Wayland Baptist Church Youth Ministry, both on and off church grounds, including the necessary transportation to and from these events and activities. Permission is granted for my child to receive medical care if: (1) such care is deemed necessary by the persons in charge of the event; (2) the proposed medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain my parental consent would reasonably jeopardize the life, health, or well-being of the child affected; (3) I cannot be personally contacted. I further agree not to hold Wayland Baptist Church or any of its paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend and hold harmless Wayland Baptist Church for all claims made and liabilities assessed against them as a result of any event or activity. I release Wayland Baptist Church and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from any event or activity. Furthermore, I understand and assume the expenses of any property damage caused by my child. Should it be necessary that my child be returned home due to disciplinary action (when on trips or while on church property), I will be contacted by the leaders and will be responsible to pick my child up and assume the cost of transportation. By typing your name below and clicking the "I Accept & Submit Form" button, you are signing this Medical & Liability Release Form electronically. By signing, you agree that you are the parent/guardian of the youth mentioned above. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept & Submit Form" you consent to be legally bound by this Release Form's terms and conditions.
Signature of Parent/Guardian
I Accept & Submit Form