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Country Bible Youth Group

All-Year Participation Agreement, Media Permission & Medical


Release Form
September 2008 to September 2009
Country Bible Church (CBC) welcomes your child’s participation in the Youth Ministry
Program. It is necessary however, for CBC and you to have an understanding regarding
CBC’s responsibility and your responsibility in the event of an accident or illness
involving any participant in the Youth Ministry Program. We, therefore, ask you to read
and agree to the following terms and conditions:

Participation Agreement
I, the parent and/or legal guardian of ____________________________, consent to allow my
child to participate in the youth group conducted by CBC. In consideration of my child
being allowed to participate in the youth group, I hereby acknowledge and agree as
follows:
1) My child’s participation in the youth group is entirely voluntary.
2) CBC shall not be responsible for any of my child’s personal property that is lost or
damaged by fire, theft, or by other participants.
3) CBC reserves the right to dismiss, temporarily or permanently, any participant whose
conduct is
deemed, by the youth directors, to be detrimental to my child, other participants, staff or
any aspect of the youth group.
4) I understand that my child may travel to or from various youth group activities in
vehicles driven by a driver approved by the directors of the youth ministry.
5) My child has health insurance coverage appropriate for his/her participation in the
youth group. I
understand that CBC does not provide any insurance for my child in connection with
his/her
participation in the youth group.
6) I hereby agree I will not sue or make claims against and I will forever release,
indemnify and hold harmless CBC, its employees, agents, successors and assigns,
singularly and collectively, from and against any blame and liability for any injury, harm,
loss, inconvenience or any other damage of any kind whatsoever, which may result from
or be connected in any way to my child’s participation in youth group activities.
7) I agree that this release covers each and every time my child participates in any
activity of CBC, whether on premises owned or operated by CBC or at any other location.

Media Permission
 Yes, I consent that CBC may use photos or video of my student in church publications
or on
their weblog or website.

 No, Please do not post pictures of my student on CBC’s publications, weblog or web
site.
Medical Release

____________________________________ ________________________________________________
Parent/Guardian Name (printed) Parent E-mail

_____________________ ________________ ____________ ______________________________


Student Name (printed) Student Birth Date Student Grade Student School

______________________________ ______________________________ ___________________


Home Address City, State, Zip Home Phone

_______________________ ____________________________ ____________________________


Parent Work Phone Parent Cell Phone Other Parent contact

______________________________ ____________________________
Name of emergency contact Emergency Contact Phone

Special Medications or Allergies: _________________________________________________________

______________________________ ______________________________
Family Doctor Name Doctor Phone

______________________________ ___________________ _________________________


Insurance Company Group # Policy #

In the event that my child is injured and I cannot be reached, I grant permission to the
adult in charge of my son/daughter to grant permission for emergency medical
treatment and I agree to be financially responsible for that treatment.
I have read and understand the above provisions and it is my intention that by signing
below I will bind myself, my spouse, the participant, and my and the participant’s heirs,
successors, executors, estate and dependents to the terms stated above.

____________________________________ ______________________________
Parent/Guardian Signature Date

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