MVYOUTH General Consent Form and Medical Release 2025-26

Young Person's Information

Legal Name

Name student goes by

Birthdate

Grade (in September)

School

Family (Guardian) Information

Parent/Guardian 1 NAME

Parent/Guardian 1 PHONE

Parent/Guardian 2 NAME

Parent/Guardian 2 PHONE

Address

Home Phone

Email Information

Please list any email addresses that should receive information about MVYouth activities (e.g., special events, camps, emergency updates). This may include parents/guardians, young people, or grandparents. By providing an email address, you consent to receive communications from Marine View Youth.

Email 1

This address will receive a confirmation email

Email 2

Email 3

Email 4

Alternative Emergency Contacts

If the Parents/Guardians above are not available who should we contact in case of emergency?

NAME of Alt. Emergency Contact #1

PHONE No. of Alt. Emergency Contact #1

Emergency Contact #1's Relationship to Young Person

NAME of Alt. Emergency Contact #2

PHONE No. of Alt. Emergency Contact #2 Name

Emergency Contact #2's Relationship to Young Person

Parent/Guardian Permission Slip

I hereby consent to participation by my child in the activities sponsored by Marine View Presbyterian Church. I understand that my child will be under the supervision of church staff and volunteers. In addition, I agree to indemnify and hold harmless Marine View Presbyterian Church, and its representatives, and volunteers, from any and all claims, including negligence, arising from or relating to my child’s participation in this event.

Parent/Legal Guardian Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Date Signed

Emergency Medical Release

I (we), the undersigned parent(s) or guardian(s) of the above-mentioned child, a minor, do hereby authorize adult volunteers of Marine View Presbyterian Church as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by any accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability Marine View Presbyterian Church any of its ministries or leaders in the event of injury during the above-mentioned event. This agreement does not apply to claims for intentional misconduct or gross negligence.

Parent/Legal Guardian 1 Electronic Signature*

Parent/Legal Guardian 2 Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Health Insurance Company

Policy or Group Number

Phone

Does your child have any medical, dietary, or special needs, including allergies?

Yes No

If yes, please explain

Please advise any known behavioral or psychiatric conditions

Medications

Medication

Dosage/Frequency

Purpose

Potential Side Effects

If necessary, my student may be given (Check all the apply)

Ibuprofen Acetaminophen Benadryl None of the above

Picture Permission

I (we), the undersigned parent(s) or guardian(s) of the above mention child, a minor, do hereby grant permission for Marine View Presbyterian Church to

Take and publish pictures of the above mentioned child on Marine View Presbyterian Church social media accounts including, but not limited to, Facebook & Instagram etc... I (we) do not give permission for pictures to be taken of the above mentioned child.

Parent/Legal Guardian Electronic Signature*

*By entering my name in the box above, I am providing my digital signature on this form.

Date signed

MVYOUTH General Consent Form and Medical Release 2025-26

Description

Please Fix the Following