Alton Youth Permission Form

Please fill out the form below. The information on this form is confidential and will only be used by church leaders to ensure your child remains safe during their time with us.

If you need to register multiple children, please refresh the page upon submission to fill out a new blank form.

Thank you!

Student Name

First Name

Last Name

My student is attending:

Please check all that apply.

Middle School youth events (grades 6-8)

Senior High youth events (grades 9-12)

Student Birthdate

YYYY

Parent 1

First Name

Last Name

Parent 2

First Name

Last Name

Parent Email

Parent Preferred Phone

(###)

###

####

Emergency Contact

First Name

Last Name

Emergency Phone

(###)

###

####

Photo/Video Release

I hereby give permission for my child to be photographed and/or video-recorded while participating in BeFree activities, and for those images to be used on the church website or other promotional materials (children will not be identified by name).

I do not give permission for my child to be photographed or video-recorded.

Medical Release

Family Physician

Physician Phone

(###)

###

####

Medical Insurance Carrier

Policy #

Please list your child’s medical conditions

Please list any allergies (food, drug, environmental)

Please list any daily medications your child is taking

This medication can be administered, with your consent, by an adult leader. Please provide the medication to an adult leader in its original bottle

I give consent for an adult leader to administer the following OTC medications

Check all that apply

Tylenol- for headache, discomfort, fever

Ibuprofen- for headache, discomfort, fever

Benadryl- allergic reaction, itchiness, hives, rash

None of the above

By submitting this form, I hereby give permission for my child named above to attend activities with BeFree Church, and to travel to off-site activities in vehicles driven by leaders age 25 and older. In the event that medical care is necessary, I hereby give permission to the medical personnel selected by church leaders to provide routine health care; to administer medications; to order x-rays, routine tests, and treatment; to release any records necessary for insurance purposes; to provide or arrange necessary related transportation; and in the event that I cannot be reached in an emergency, I hereby give permission for the physician selected by church leaders to secure proper treatment, including hospitalization for my child named above.

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