2018 Youth & Child General Release Form

Please fill out this form and click submit.
Child/Youth Information

Please select one option.
Guardian Information

Emergency Contact

Parental Consent

The undersigned does hereby give permission for my child (“Participant”), to attend and participate in any Peace Reformed Church children/youth ministry activities, events, retreats and childcare during the period of January 1, 2018-December 31, 2018.

LIABILITY RELEASE: In consideration of Peace Reformed Church allowing the Participant to participate in children/youth ministry (Sunday worship, Sunday meeting, Wednesday midweek, Activities, Events, Retreats, Lock-Ins, Trips) and childcare, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Peace Reformed Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I the parent or legal guardian of this Participant hereby grant my permission for the Participant to participate fully in children/youth ministry activities and child care, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

TRANSPORTATION PERMISSION: The undersigned does also hereby give permission for my child/youth to ride in any vehicle driven by an approved and licensed ADULT chaperone while attending and participating in activities sponsored by Peace Reformed Church. My child/youth and I understand that SEAT BELTS MUST BE WORN AT ALL TIMES during transportation.
Medical Information

Primary Care Physician

Insurance Information


List all medications the youth will take during any youth ministry trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements and vitamins. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.
Please select one option.
MEDICAL CONDITIONS: Please answer in detail if applicable or write N/A. Attach additional pages if necessary.
Covenant of Community Expectations

The following rules and guidelines are equally binding on adult leaders/chaperones and youth.

Any participant failing to abide by these rules will be sent home immediately at personal/family expense.
• No use of illicit drugs or alcohol
• Presence at and full participation in all group activities, including adherence to curfews and other time-related instructions
• No sexual misconduct (defined as exposure, touching, or inappropriate reference to body areas normally covered by undergarments)
• Must be in assigned rooms by designated time
• Coed visitation only in assigned community room
• Smoking and the use of tobacco products are not allowed to, from, or during any trip.
• Will not break any American laws in the United States or any other country.
• Adults and youth will be equally responsible for performing assigned tasks in a timely and cooperative manner.
• Participants will be respectful, encouraging, and will maintain a positive attitude toward others at all times, recognizing Christ’s presence in each other.
• Participants will be respectful of both common living spaces and the property of others.
• Participants will avoid the use of foul language, cursing, or any speech (including “humor”) which puts down, makes fun of, or stereotypes other persons or groups.
• Sleeping areas for males and females will be separate.
Youth Participant’s (or Adult Leader’s) Statement: By typing my name on the line below, representing my signature, I pledge to honor God and respect others during this activity by following the rules and guidelines printed above. I understand that I cannot participate in the activity unless this completed form is on file.
Parent/Guardian’s Statement: By typing my name on the line below, representing my signature, I agree to support the Covenant of Community Expectations printed above, and will accept responsibility for the payment of my child’s return transportation should s/he break one of the non-negotiable rules.
Photo Release Form for Children and Youth

I agree that Peace Reformed Church may photograph and record my child/dependent’s likeness and activities (Images) during church-related activities. I grant the following rights to Peace Reformed Church: permission to use and re-use, publish and re-publish, and modify or alter the Image(s) taken during the shoot. Use of the Images for editorial, commercial, trade, advertising, and any other purpose may be done in any medium now existing or subsequently developed, on the church website and on the Internet, and worldwide in perpetuity for the purposes stated above.

I waive my right to inspect or approve any editorial text or copy that is used in connection with the Images and release and discharge Peace Reformed Church from any and all claims arising out of use of the Images for the purposes described above, including any claims for libel, invasion of privacy, or other tortuous act.

I have read the foregoing. I fully understand its contents, understand that this agreement does not expire, and confirm my agreement by signing below. I am over the age of 21 and have legal capacity to sign the release.
Type parent/guardian signature in the line below, understanding that it represents your signature.


Please fill out this form and click submit.