Bethel Christian Church
Children & Youth Ministries
 Medical Release & Permission Form

Name:_______________ Phone:_______________ Address: _____________________________  City/State/Zip: _______________________________________________________________________

School:____________________________________ Grade/Year:__________________________________

I give permission for my above-named child to join the children/youth group of Bethel Christian Church on (date)______________________________________________________________ to attend (event)_________________________________ in (city) _______________________________________,  (State)____________________.  I understand that the group will be traveling out of town for the event.  I also understand that there will be a cost for the event.

I hereby release Bethel Christian Church and its staff and sponsors, from responsibility and liability for any injury, illness, or even death that my child may sustain during the activity.   In the event of an emergency, I hereby authorize an adult leader of the activity, as an agent for me, to consent to an x-ray examination; medical, dental, surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital.  I expect to be contacted as soon as possible.

I realize that my child’s behavior is my responsibility.   I will instruct my child in proper behavior and to follow all guidelines set down by Kenny Stokes or any other recognized adult leader of Bethel Christian Church.   In the event of behavior or discipline problems, I understand that I will be contacted to correct the problem and/or to pick up my child (or make arrangements to do so).

_______________________                          ____ / ____ / ____
Signature of legal guardian                            Date

____________________________________
Print Name

Emergency Phone Number: _______________      Medical Information: ____________________

Allergies: _____________________________      Medications being taken:_________________

Insurance Co. & Policy #:__________________________________________________________

**  This form must be completed in its entirety and returned to Bethel Christian Church before departure.  This form can also be faxed to the church office (770) 483-9235.