Parental Consent, Release, & Authorization Form

Parental Consent, Release, & Authorization Form

For participants under 18. This authorization remains in effect from7/13/22 through 8/31/23.
Parent/Guardian's Name *

First Name Last Name
Parent/Guardian's Email *
example@example.com
Parent/Guardian's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Child's Name *

First Name Last Name
Child's Grade *
Child's Date of Birth *

Month Day Year
Date (mm-dd-yyyy)
Gender *

Male Female
Child's Cell Phone Number (if applicable)

Area Code Phone Number
Food Restrictions *

Vegan Vegetarian Kosher Halal Milk Allergy/Intolerance Gluten Allergy/Intolerance Peanut Allergy Tree Nut Allergy Egg Allergy Soy Allergy Shellfish Allergy None
Non-Food Allergies
Medications Policy

It is the policy of SWHBC not to administer either prescription or non-prescription medications to the children/youth under our care. Medications should be administered by a parent at home. Parents are reminded of our sick child policy. Exceptions to the medications policy may be granted to parents of children/youth/vulnerable adults with potentially life-threatening conditions (such as asthma or severe allergic reactions). Parents of such persons should address their situation with the ministry leader to develop a plan of action to allow a designated volunteer(s) to maintain and administer the medication. Additionally, for overnight or extended day activities, parents will have opportunity to specify instructions for distribution of over-the-counter and prescription medications. Children/youth are not permitted to carry, maintain, nor share medications - prescription and/or non-prescription - at SWHBC sponsored activities.
Acknowledgement *

I have read and understand the Medications Policy
Medications & Instructions
Over-the-Counter (OTC) Medications *

My child may not take any OTC medications while under your care. My child may only take OTC medications that I send with him/her (specify types and instructions above, under "Medications & Instructions"). You may give my child OTC medications as necessary (select from list below).
Allowed OTC Medications

Ibuprofen (Motrin, Advil, etc.) Acetaminophen (Tylenol, etc.) Naproxen (Aleve, etc.) Aspirin Benadryl Claritin Allegra Zyrtec Hydrocortisone cream Neosporin Sudafed Dextromethorphan (Delsym, Robitussin, Benylin, etc.) Guaifenesin (Mucinex, etc.) Dayquil Nyquil Menthol throat lozenges (Halls, Robitussin, etc.) Tums Pepto-Bismol Imodium Dramamine
Chronic Conditions
Health Insurance Carrier *
Named Insured *

First Name Last Name
Policy/Group Number *
Emergency Contact 1 *

First Name Last Name
Emergency Contact 1 Phone Number *

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Emergency Contact 2 Phone Number

Area Code Phone Number
I, the parent or legal guardian of above registered child, grant SOUTHWEST HILLS BAPTIST CHURCH my permission to use photos taken while at Southwest Hills or while at events held by Southwest Hills for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. *

Yes, I grant permission to Southwest Hills Baptist Church to use photos of my child for the above stated uses. No, I do not grant permission to Southwest Hills Baptist Church to use photos of my child.
Parental Consent, Release, & Authorization

I am the parent and/or legal guardian or the above-named child, and I hereby warrant my legal authority to provide consent herein. Based on said authority, I hereby authorize said child to participate in any event associated with SOUTHWEST HILLS BAPTIST CHURCH and to travel with the adult staff/volunteer/other(s) in connection with his/her participation in such event(s).

I hereby further release, indemnify and hold harmless SOUTHWEST HILLS BAPTIST CHURCH of Beaverton, OR, together with its staff, employees, authorized representatives and named volunteers of and from any and all liability for injuries, claims, demands or damages, known and unknown, whether for physical or mental injury, or illness, or property damage, that may result from the participation of my child in the event(s) listed above, or travel to or from said event(s), during the dates indicated, EXCEPT for conduct of said persons that is willful, wanton, or grossly negligent.

In the event of an injury, damage, or other medical emergency involving my child, I hereby authorize the above-named leader(s) to consent to administration of emergency care and treatment, x-ray examination, diagnosis and/or hospitalization for my child; PROVIDED, HOWEVER, that such emergency care is, in the professional judgement of a duly licensed physician, surgeon, nurse, EMT or dental professional, reasonably necessary to avoid life-threatening or irreparable injury, harm, or damage. OTHERWISE, it is hereby agreed and understood that said group leader(s) shall be authorized to consent to such emergency care and treatment, x-ray examination, diagnosis and/or hospitalization only after making reasonable efforts to contact me by telephone or otherwise so as to allow me to consent directly to such emergency treatment as the parent and/or legal guardian of said child. In the event the subject activity is being conducted at a remote location where access to medical care and treatment is not readily available, I understand and accept the risks and delays inherent to and associated with obtaining medical care and treatment in such remote locations.

Subject to the foregoing, I further understand and agree that I and my insurance carrier, if any, assume full responsibility for payment of any and all reasonable and necessary costs and expenses related to such emergency treatment and hereby indemnify and hold harmless SOUTHWEST HILLS BAPTIST CHURCH of Beaverton, OR, together with its staff, employees, authorized representatives and other event participants, from any liability for such costs and expenses. I further understand that if, in the reasonable judgment of the event leader(s), it is necessary for my child to return home due to medical reasons or otherwise, the undersigned shall assume and be responsible for the payment of all transportation costs.

I understand that SOUTHWEST HILLS BAPTIST CHURCH believes that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church (see Matthew 18:15-20; 1 Corinthians 6:1-8). Therefore, the parties agree that any claim or dispute arising from or related to this agreement shall be settled by biblically-based mediation and, if necessary, legally binding arbitration, in accordance with the Rules of Procedure of Peacemaker Ministries of Billings, Montana.

I have read and understood this form in its entirety, and I have signed the same voluntarily and not under duress or other compulsion. I further represent that the information provided herein is true, complete and accurate to the best of my knowledge and belief.
Acknowledgement *

I acknowledge the above.
Signature *

This digital signature is legally binding. Clear
Today's Date *

Month Day Year
Date (mm-dd-yyyy)
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